Basic Environmental Health

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BASIC
ENVIRONMENTAL
HEALTH
BAS IC
ENVIRONMENTAL
HEALTH
Annalee Yassi
lord Kjellström
Theo de Kok
Tee L. Guidotti
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OXFORD
UNIVERSITY PRESS
2001
OXFORD
UNIVERSITY PRESS
Oxford New York

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Copyrighl © 2001 by the World Health Organization

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l.ihrary of Congress Cataloging-in-Publication Data

Basic environmental health / Annalee Yassi let al..
p. cm. Iticludes bibliographical relereitces and index.
ISBN 0-19-51 3558-X
1. Environmental health.
1. Yassi, Annalee.
RA565.B376 2001 61 5.9'02—dc2 1 00-032400
98765432
Printcd in the United States of America
on acid-free paper
PREFACE
This book is intended to be used as a textbook at the university level. It is basic

and interdisciplinary in its approach, in recognition of the wide variety of pro-
fessional groups for whom training in environmental health is desirable. The text
is only one component of a "teaching kit" in environmental health; a Teacher's
Guide, with a variety of interactive exercises, and a chart book of tables and
graphs, ready for transparency projection, supplement the text (available from
EHG, WHO, 1211 Geneva, Switzerland, Fax: +41-22-7914123, email:pfisteratit
who.ch; www.who.int/Isearcb the Environment program).
The target groups for the book include university students in ptiblic health,
medicine, nursing, other health professions, engineering, environmental science,
management, and others needing a basic introduction to environmental health
(including students interested in environmental law, geography, urban planning
and social work). The book and the teaching kit can be used in courses to form
a component of a traditional program at university level, or in stand-alone courses
for in-service training of government agency staff, industry professionals and
managers, and interested people in non-governmental organizations or commu-
nity groups.
The textbook is divided into 12 chapters, each with defined objectives. The
first section, Chapters 1-4, introduces the concepts and methods applied in en-
vironmental health. Chapter 1 is an overview of the macro-level influences on
health, touching on various social science disciplines. Chapter 2 describes the na-
ture of environmental health hazards, introducing toxicology, microbiology,
health physics, injury analysis, and psychosocial concepts. Chapter 3 lays out the
basic approach to risk assessment and includes a discussion of epidemiological
methods. Chapter 4 outlines the principles of risk management. The second sec-
tion organizes the discussion by route of exposure. Chapter 5 addresses air qual-
ity; Chapter 6 water and sanitation; and Chapter 7 food and agricultural issues.
The third section is sustainable development: Chapter 8—settlements and ur -
banisation, Chapter 9–energy, Chapter 10–industry, and Chapter 11–global con-
cerns. Chapter 12 ties the course together focusing on ethical issues and the con-
crete application of the course material.
Thus the book can form the basis of a full semester course or its equivalent.
While it is meant to be a "primer," extensive referencing to other publications
should allow as comprehensive a coverage of any topic as the educational set-
ting requires.
V
The problem solving exercises in the Teacher's Guide can be used to adjust
the level of complexity of the course for individual students or the class as a
whole. In interdisciplinary classes, for example, the teachcr may require more
in-depth research from students in the areas of their OWfl disciplines compared
to others in different disciplines, who would in turn focus on areas of their own
expertise. This permits each student to achieve a maximum learning experience
while contributing optimally to the group. It also simulates the real world sce-
nario in which professionals in different disciplines are expected to understand
each other, while depending on each other for the more complex details.
The text and teaching kit are part of a sustained effort by WHO, UNEP,
UNESCO, and CRE to promote strengthened teaching in environmental health
for a wide variety of students at university level.
Winnipeg, Manitoba, Canada A.Y.

Auckland, New Zealand T.K.
vi Preface
ACKNOWLEDGMENTS
This text was developed with the assistance of the United Nations Environment
Programme (UNEP), Conference of European University Rectors (CRE), and the
United Nations Educational Scientific and Cultural Organisation (UNESCO), and
under the overall auspices of the Office of Global and Integrated Environmental
Health of the World Health Organisation (WHO). It was tested at workshops in
Visby, Sweden; Budapest, Hungary; Cape Town, South Africa; and Amman, Jor -
dan where valuable comments were provided by the participants. Comments re-
ceived in meetings of reviewers held in Geneva in June 1994 and November
1995, and by many others were also incorporated.
Dr. Theo de Kok (University Maastricht, The Netherlands), the third author
of the book, has been developing distance learning materials, in conjunction with
this text. Merri Weinger (education specialist, WHO) is the primary author of the
Teacher's Guide.
There are many people who have made valuable contributions to this text to
date; these and others will hopefully continue to contribute by supplying case
studies from which others could learn. Among the many contributors, several
stand out for specific mention.
Dr. Jerry Spiegel (formerly of Manitoba Environment, Winnipeg, Canada and
now with the Liu Centre for the study of Global Issues at the University of British
Columbia, Vancouver, Canada) served as the major editor of the book and con-
tributed substantially to the chapter on risk management. He also wrote a large
section of the industry chapter and extensively rewrote other parts of the text.
Dr. Alan Pinter (Johan Bela National Institute of Health INIHI, Budapest, Hun-
gary), and Dr. Evert Nieboer (McMaster University, Hamilton, Canada) both had
substantial input to the book, particularly to the toxicology sections, and Dr.
Avrum Regenstreif had major input to the chapter on settlements and urban de-
velopment. The following individuals (listed in alphabetical order) also served as
reviewers and contributed valuable comments and materials:
Dr. Pedro Más Bermejo, Director, National Institute of Hygiene Epidemiology and
Microbiology, La Hahana, Cuba
Dr. Helen Dolk, London School of Hygiene and Tropical Medicine, London, UK
Professor Hunay Evliya, Cukurova University, Turkey
Professor Maria Alvim Ferraz, University of Oporto, Portugal
Professor H.N.B. Gopalan, UNEP, Nairobi, Kenya
VII
Dr. Steve Hrudey, University of Alberta, Canada
Dr. Steven Markowitz, Mount Sinai School of Medicine, New York, USA
Dr. S. Miyagawa, Division of Food and Nutrition, WHO, Geneva
Dr. Monica Nordberg, Karolinska Institute, Stockholm, Sweden
Dr. Peter Orris, Cook County Hospital, Chicago, USA
Dr. Peri Pamir, CRE, Geneva
Dr. David Rapport, University Guelph, Canada
Dr. Yasmin von Schirnding, Environmental Health, Johannesburg, South Africa
Dr. Cohn Soskolne, University of Alberta, Canada
Dr. Carl-Einar Stalvant, Stockholm University, Sweden
Ms. Adrienne Taylor, Auckland, New Zealand
Professor Dr. Henk van de Plas, Copernicus Steering Committee, The Netherlands
Dr. Susan van de Vynckt, UNESCO, Paris
and others.
In addition, valuable assistance in assembling the material was provided by

Sandrine Chorro (France), and Elissa Neville and Ingra Schellenbcrg (Canada).
The enormous help provided by Simone Beaudet, Lisa Springer, Mavis Puchlik,
Dr. Sande Harlos, and Dr. Anthony Morham at the University of Manitoba
(Canada) was invaluable; as was the editing assistance provided by Donne
Flanigan and Jennifer Dundas. The skillful proofreading and editing conducted
by Myrna McGill was especially appreciated.
The support of the Occupational and Environmental Health Unit in the De-
partment of Community Health Sciences at the University of Manitoba, where
this book was drafted, rewritten, edited and assembled, deserves special recog-
nition. This project was partially funded through a Programme Development
Grant from this University.
The Occupational Health Program of the University of Alberta (Canada) con-
tributed to the production of this work and managed final preparation of the fig-
ures. The artwork was drawn, adapted, or enhanced for this book by Ms. Sam
Motyka, Health Sciences Media Services, University of Alberta Hospitals, Capital
Health Authority, Edmonton, Alberta (Canada). Funding for the preparation of
some figures came from the Tripartite Fund for Occupational Health at the Uni-
versity of Alberta.
The final review and editing was coordinated by Dr. lord Kjcllström at the
University of Auckland with the assistance of Suzanne Jackson and Adrienne
Taylor.
viii Acknowledgments
CONTENTS
Introduction, 1
Birth, Life, Death, and the Environment, 2
Health and the Environment, 3
Historical Perspective, 10
Basic Requirements for a Healthy Environment, 14
Measuring Environmental Quality, Human Exposure, and
Health Impact, 18
Patterns of Illness Throughout the World, 21
Impact of Environmental Factors on Health, 35
Links Between Environmental and Occupational Health, 38
Obstacles to and Opportunities for Resolving Environmental
Health Problems, 41
Role of the Environmental Health Professional, 46
Nature of Environmental Health Hazards, 52

Hazards and Risks, 53
Biological Hazards, 55
Chemical Hazards, 61
Physical Hazards, 80
Mechanical Hazards, 92
Psychosocial Hazards, 102
Risk Assessment, 104

The Health Risk Assessment and Risk Management Framework, 105
Epidemiological Methods, 107
Hazard Identification in the Field, 118
Relationship Between Dose and Health Outcome, 119
Human Exposure Assessment, 128
Health Risk Characterization, 137
Health in Environmental Impact Assessment, 139
Risk Management, 143

The Approach to Managing Risk, 144
Risk Evaluation, 144
Factors Affecting the Perception and Acceptance of Risk, 146
Prevention and Control of Exposure to Environmental Hazards, 150
Risk Monitoring and Use of Indicators, 160
Ix
Special Problems in Managing Environmental Health Risks, 164
Cost-Effectiveness and Cost-Benefit Analysis of Interventions, 172
Air, 180
Overview of Air Pollution, 180
Common Health Effects of Ambient Air Pollution, 188
Health Effects of Specific Air Pollutants, 190
Industrial Air Pollution, 198
Air Pollution and the Community, 201
Water and Sanitation, 209

Why Water is Essential, 209
Water Quality, Sanitation, and Health, 210
Adequacy of Freshwater Supply to Meet the Worlds Needs, 217
Drinking-Water Quality Criteria, 220
Drinking-Water Supply and Monitoring, 227
Sanitation, 231
Control of Water Pollution, 234
Recreational Water Quality Guidelines, 236
Ensuring a Safe and Sufficient Water Supply, 237
Food and Agriculture, 242

Health and Nutrition, 243
Foodborne Diseases and Food Poisoning, 248
Food Quality Criteria, 259
Food Quality Assurance, 262
Global Food Production Capacity and Food Security, 268
Environmental and Occupational Health Hazards in Agriculture, 273
Human Settlement and Urbanization, 281

The Nature and Requirements of Human Settlements, 282
Housing and Health, 288
Factors Causing Increased Urbanization, 293
Rural Economic and Social Development, 295
Urbanization and Health, 297
The "Healthy Cities" Approach to Prevention, 306
Health and Energy Use, 311

Human Energy Needs, 311
Biomass Fuels, 315
Fossil Fuels, 318
Hydropower, 322
Nuclear Power, 325
Alternative Energy Sources, 328
Comparing Risks, 330
Priorities for Action, 330
x Contents
Industrial Pollution and Chemical Safety, 332
Extent of Industrial Pollution, 333
Public Exposure From Industrial Sources, 333
Hazards by Industry, 340
Major Chemical Contaminants of Concern in the General
Environment and the Workplace, 344
The Social Context of Occupational Health and Safety, 350
Dimensions and Types of Occupational Health Problems, 354
Industrial Environmental Accidents, 362
Approaches to Prevention, 363
Transboundary and Global Health Concerns, 368

Health Consequences of War, 370
Ozone Depletion and Ultraviolet Radiation, 375
Climate Change and the Greenhouse Effect, 378
Deforestation and Desertification, 387
Biodiversity, 390
Acid Precipitation, 392
Transboundary Movement of Hazardous Waste, 393
Disasters, 394
Global Chemical Contamination, 397
Action to Protect Health and the Environment, 399

From Knowledge to Action, 399
Ethical Principles That Guide Action on Environmental Health, 401
Role of Environmental Health Professionals, 401
Index, 421
CONTENTS xi
BASIC
ENVIRONMENTAL
HEALTH
1
INTRODUCTION
LEARNING OBJECTIVES
After studying this chapter you will be able to do the following:

• explain the basic relationship between environmental factors and health,
and how the interrelationship between economic development, the envi-
ronment, and health can be seen in an ecosystem framework
• interpret environmental health in historical context with respect to changes
in technology, economic development, and social organization
• describe the basic requirements for a healthy environment
• discuss the importance of the workplace to environmental health
• explain the basic issues and concerns with respect to methods of measur-
ing environmental quality, exposure, and health effects
• describe the larger socioeconomic issues affecting environmental health
CHAPTER CONTENTS
Birth, Life, Death, and the Environment Safe and Sufficient Water
Health and the Environment Adequate and Safe Food
An Ecosystem Perspective Safe and Peaceful Settlements
Definitions of Health and Stable Global Environment
Environment Measuring Environmental Quality,
Human Interaction with the Human Exposure, and Health Impact
Environment Measuring Environmental Quality
Human Ability to Adapt Measuring Human Exposure to
Supportive Environments for Environmental Hazards
Health Determining Health Elfects and
Historical Perspective Risks in Human Populations
Economic and Industrial Develop- Environmental Health Monitoring
ment and Environmental Health Patterns of Illness Throughout
The First Environmental Crisis the World
The Second Wave of Environmen- Demographic and Epidemiological
tal Concern Transitions
The Third Wave of Environmental Mortality Trends
Concern Burden of Disease
Basic Requirements for a Healthy Vulnerable Groups
Environment Impact of Environmental Factors
Clean Air on Health
Links Between Environmental and Obstacles to and Opportunities for
Occupational Health Resolving Environmental Health
Importance of the Workforce Problems
Linked Environmental and Demographic Issues
Occupational Health Hazards Poverty
Common Approaches and Human Consumption Patterns
Resources Macroeconomic Policies
The Workplace as a Sentinel for Role of the Environmental Health
Environmental Hazards Professional
The Total Exposure Concept You Can Make a Difference
Consistency in Setting Standards The Multidisciplinary Team
Incentives for Prevention
BIRTH, LIFE, DEATH, AND THE ENVIRONMENT

When human beings first appeared in the world, their maximum life expectancy
is believed to have been around 30 or 40 years. Due to the hostile environment
in which they lived, they had a short life expectancy compared to that which
characterizes most societies today. Still, it was long enough for them to have chil-
dren and to establish themselves as the species most capable of modifying their
environment for better or worse.
To survive, the first humans had to cope with the following:
• the constant search for sufficient food and drinking water while avoiding plants
that contained natural toxins (like poisonous toadstools) or rancid infected
meat
• infections and parasites that spread from person to person or animal to per-
son, often through food, drinking water, or insect vectors
• injuries from falls, fires, and animal attacks
• cold and hot temperatures, rain, snow, natural disasters, and other adverse
conditions.
These health hazards all occurred in the natural environment. In some soci-
eties the "traditional hazards" listed above still dominate environmental health
concerns. However, as human beings brought these hazards under control in
some regions, "modern hazards" caused by technological and industrial devel-
opment took over as the primary threat to health and well-being.
Over the last few decades, life expectancy has increased significantly in most
countries, as examples of survival curves show (Fig. Li). Some investigators say
that this is largely due to improvements made in the living environment. Oth-
ers say that improvements in nutrition are an essential reason for longer lives.
Still others say that the changes could not have happened without improved
medical diagnosis and treatment of illnesses. All of these statements are proba-
bly correct. Progress in health has gone hand in hand with improvements in en-
vironmental quality, nutrition, and medical care. People who are sick now are
more likely to survive because of improved medical care, and the much greater
number who are healthy at any given time are likely to stay healthy and fit be-
cause of improved nutrition and control of environmental health hazards. Pro-
2 Basic Environmental Health

World Least developed countries
100 100
90 90
0, 80 ............ . . ..... 2 80
0 0
> 70 •~ 70
> >
0,
60 60
0 o 50
50
a) a)
0) 0)
Ca 40 40
0 0
a)
U 30 30
a) a)
0 20 o 20
10 10
0 0
0 5 10152025303540455055606570758085+ 0 5 10152025303540455055606570758085+
Age Age
— 1955 1975 — — 1995 ..-. 2025
Figure 1.1 Survival curves, 1955-2025. From WHO, 1998a, with permission.
jections of survival and world population through to year 2025 indicate a con-
tinual improvement of life expectancy (Fig. 1.1).
Environmental health science is essentially about two things: hazards in the
environment, their effects on health, and the variations in sensitivity to expo-
sures within populations; and the development of effective means to protect
against hazards in the environment. This book will describe the major environ-
mental hazards that can affect health, show how these hazards can be assessed,
and demonstrate how the resulting adverse health effects can be reduced or
avoided. The roles of various professionals in protecting health will be explored
and the fundamental principles that all environmental health professionals need
to understand, regardless of where they work, will be described.
HEALTH AND THE ENVIRONMENT

An Ecosystem Perspective
The term ecosystem, coined in the 1930s, can be defined as a system of dynamic
interdependent relationships among living organisms and their physical envi-
ronment. It is a bounded entity that has acquired self-stabilizing mechanisms and
an internal balance that has been evolving over the course of centuries. Within
a stable ecosystem one species does not eliminate another; otherwise the food
supply of the predator species would disappear. Stable and balanced ecosystems
will survive longest. An ecosystem cannot sustain massive amounts of materials
and energy being consumed by one species without depriving other species and
eventually endangering the viability of the entire ecosystem. Similarly, an ecosys-
tern's capacity to absorb wastes and to replenish soil and fresh water is not lim-
itless. At some point an external load can overwhelm the ecosystem's balance,
resulting in rapid change or a collapse of the ecosystem. Just as the concept of
homeostasis (the body system's capability to function in a coordinated way to
ensure the constancy of its internal environment) is now generally understood
INTRODUCTION 3
pox 1.1
The Gaia Hypothesis
James Lovelock, a British atmospheric scientist, advanced the hypothesis that the
earth and all its components (including the geosphere and the water, gas, nutrients,
energy cycles, and all living organisms) constitute a global homeostatic mechanism
that ensures constancy of the environment. This hypothesis is known as the Gaia
hypothesis, as the word Gala comes from the Greek goddess Mother Earth. Lovelock
contends that the global biosphere acts in a self-regulating manner, using feedback
mechanisms to counter externally imposed disturbances. For example, the heat out-
put of the sun has increased by about 30% since our planet was formed. Yet the
earth has maintained a relatively constant temperature. This is believed to be due
to the increased solar energy stimulating an increase in photosynthesis, which re-
duces carbon dioxide levels in the atmosphere. This in turn reduces the "green-
house" capacity of the atmosphere, causing it to cool and thereby compensate for
more heat from the sun. Similarly, the Gaia hypothesis suggests that oxygen has
accumulated in the atmosphere to a level that is optimal for biological life on Earth,
reflecting the balance of positive and negative feedback from the variety of inter-
dependent living organisms. These changes have taken place very slowly over thou-
sands or millions of years, while the currently debated increase in greenhouse gases
has taken place in a few decades.
The controversy surrounding the Gaia hypothesis is due in part to the fact that
it cannot be scientifically tested. Additionally, the hypothesis is seen by some in-
vestigators to imply that nature acts in a purposeful manner, a concept that does
not fit comfortably with the mechanistic view of the world that prevails in con-
temporary Western civilization. Nonetheless, the Gala hypothesis has stimulated
awareness of the interdependencies within ecosystems and the balance of nature,
which, within limits, serve to sustain the planet's life support systems.. It has also
provtded a powerful vision or analogy for treating the Earth with the same respect
one would show a mother.
Source: Lovelock, 1988; see also McMichael, 1993.
and accepted, these complex, compensating mechanisms seem to apply to ecosys-

tems as well (see Box 1.1).
Definitions of Health and Environniejit

In the Constitution of the World Health Organization, health is defined as "a state
of complete physical, mental and social well-being and not merely the absence of
disease or infirmity" (WHO, 1948). This is the most commonly quoted modern de-
finition of health. The concepts of disease, disability, and death tend to be much
easier for health professionals to address than this idealistic concept of health. As
a result, health sciences have largely been disease sciences since they focus on treat-
ing illness or injury rather than enhancing health. In some languages (e.g., Swedish)
distinct terms for sick care and health care are in common usage, but unfortu-
nately, this difference is not articulated in the English language.

Similarly inclusive definitions of environment in the context of health have
been proposed. Last (1995) defined environment as "[All] that which is external
to the individual human host. [It] can be divided into physical, biological, so-
cial, cultural, any or all of which can influence health status in populations."
This definition is based on the notion that a person's health is basically deter-
mined by genetics and the environment. From the parents of an individual
come genetic factors (genes), consisting of the DNA in each body cell. The genes
existed when the embryo was first formed and do not generally change during
the course of one's life. If a gene does change (as in the case of a mutation),
it may lead to loss of function, cell death, and occasionally to cancer, as a re-
sult of very specific mutations. Some studies have suggested that genes provide
a built in "clock of self-destruction," as the body can only function properly for
a limited time. The limit for most individuals is within the range of 70 to 100
years. An individual's genetic material is one of the major factors that deter -
mines how he or she is affected by environmental exposure. While everybody
will have problems if subjected to high enough exposures to an environmen-
tal hazard, some people are affected at lower exposures because they have pre-
existing or concomitant risk factors or conditions, and some people are affected
at quite low exposures because of an inherited susceptibility (Jedrychowski and
Krzyzanowski, 1995).
Poverty, poor living and working conditions, and lack of education have been
repeatedly identified as major impediments to health. Over the years it has be-
come clear that substantial improvements in health cannot be achieved without
improvements in social and economic conditions. Providing relevant health ser-
vices in the context of these conditions is addressed in the Health for All policy
of the World Health Organization (WHO), established at a conference in Alma
Ata in 1978. The final declaration stated that a goal of governments, interna-
tional organizations, and the world community should be "the attainment by all
people of the world by the year 2000 of a level of health that will permit them
to lead a socially and economically productive life." It was explicitly noted that
this could be attained only through a fuller and better use of the world's re-
sources: "Health is only possible where resources are available to meet human
needs and where the living and working environment is protected from life-
threatening and health-threatening pollutants, pathogens and physical hazards"
(WHO, 1992a).
Environmental pollution and degradation have a huge impact on people's
lives. Every year hundreds of millions of people suffer from respiratory and other
diseases associated with indoor and outdoor air pollution. Hundreds of millions
of people are exposed to unnecessary physical and chemical hazards in the work-
place and living environment. Half a million die as a result of road accidents.
Four million infants and children die every year from diarrheal diseases, largely
as a result of contaminated food or water. Hundreds of millions of people suffer
from debilitating intestinal parasites. Two million people die from malaria every
year while 267 million are ill with it at any given time. Three million people die
each year from tuberculosis and 20 million are actively ill with it. Hundreds of
millions suffer from poor nutrition. Almost all of these health problems could be
prevented (WHO 1992a).
INTRODUCTION 5
As noted in the book Our Planet, Our Health (WHO, 1992a), the responsibil-
ity for protecting and promoting good health extends to all groups in society. No
longer is good health the responsibility of only traditional health care profes-
sionals, such as doctors, nurses, sanitary engineers, and safety officers, who seek
to cure disease, care for the sick, remove pathogens, and reduce injuries. Human
well-being is now clearly the responsibility of planners, architects, teachers, em-
ployers, industrial managers, and all others who influence the physical or social
environment. That is why this book is geared for teaching people in many pro-
fessions. Naturally, health professionals have a special role in environmental
health, but they need to work with all groups in society to promote good health.
The ability to work in teams and adopt a transdisciplinary approach is key to be-
ing able to solve environmental health problems (Somervile and Rapport, 2000).
Human Interaction with the Environment

Human health ultimately depends on a society's capacity to manage the inter-
action between human activities and the physical, chemical, and biological en-
vironments (Fig. 1.2). It must do this in ways that safeguard and promote hu-
man health, while at the same time protecting the integrity of the natural systems
on which a healthy environment depends. The physical and biological environ-
ments include everything from the immediate home and work environments to
regional, national, and global environments. This includes maintaining a stable
climate and continued availability of safe environmental resources (soil, fresh
water, clean air). It also includes continued functioning of the natural systems
that receive the waste produced by human societies without exposing people to
pathogens and toxic substances and without compromising the well-being of fu-
ture generations.
The idea of an inextricable link between human health and the environment
has long been recognized. Over 100 years ago, Chief Seattle, an indigenous leader
The scale and nature of human activities

(agricultural, industrial, and energy production, the use
and management of water and wastes; urbanization; the
distribution of income and assets within and between
countries; the quality of health services; and the extent
of protection of the living, working, and natural
environment)
7/ HEALTH
Physical and chemical environment Biological environment

(air, water, food and soil chemical composi- (type and distribution of pathogens
tion including radiation; climate including and vectors, as well as their habitats)
temperature, humidity, precipitation, and
seasonal changes)
Figure 1.2 Interaction between human activities and the physical, chemical, and biological en-
vironments. Adapted from WHO, 1992a, with permission.

in Washington Territory during the western expansion of the United States, spoke
movingly of our relationship to earth in a much-quoted speech: "We are a part
of the web of life and whatever we do to the web we do to ourselves.' Thus,
when we think of health as a state of complete physical, mental, and social well-
being, we must recognize that this also implies a context of ecological well-
being.
The concept of sustainable development requires that a modern economy not
harm the environment to the extent that it closes off opportunities for future
generations. Thus, the World Commission on Environment and Development
(WCED), in the report, Our Common Future, defined "sustainable development"
as "[d]evelopment that meets the needs of the present without compromising
the ability of future generations to meet their own needs" (WCED, 1987). To
promote health, which implies the full development of human potential, an ad-
equately prosperous economy, a viable environment, and a convivial commu-
nity are needed (Dean and Hancock, 1992). These qualities should be reflected
in a society's economic activity, which must not destroy the human and social
capital or the resources of society. The benefits of economic activity need to be
equitably distributed both within and among nations, societies, and communi-
ties (Hertzman et al., 1994). Because of the need for this kind of distribution, eq-
uity is an integral part of sustainable development. Agenda 21, the United Na-
tions Program of Action for Environment and Development, agreed upon at Rio
de Janeiro in 1992, reiterated this relationship, stating that "h]uman beings are
at the centre of concerns for sustainable development. They are entitled to a
healthy and productive life in harmony with nature" (UN, 1993). While virtu-
ally every aspect of human health is closely linked to the physical and social en-
vironment, we will focus here on the interaction between health and the envi-
ronment according to the factors described in Figure 1.2: biological pathogens and
their vectors and reservoirs; physical and chemical agents in an environment that
are independent of human activities and can impair human health by either their
presence (e.g., naturally occurring radionuclides, ultraviolet light) or their ab-
sence (e.g., iodine, iron); and noxious physical and chemical agents added to the
environment by human activities (e.g., nitrogen oxides, polycyclic aromatic hy-
drocarbons, particulates arising from fossil fuel combustion, waste produced by
industry, biomedical waste, and radioactive waste).
Socioeconomic factors control how resources are used. Whether a person is
hungry, adequately fed, or overfed, depends not only on the state of his or her
natural resources but also on the socioeconomic factors that influence such things
as how agricultural practices result in use or misuse of those resources and
whether safe, nutritious, and affordable food is available. Health also depends on
how people feel about their society—including how much trust and social cohe-
sion exists in their community (Putnam, 1993; Kawachi et al., 1999). The fol-
lowing definition of environmental health is thus applicable: "Environmental health
comprises those aspects of human health, including quality of life, that are de-
termincd by physical, biological, social, and psychosocial factors in the environ-
ment. It also refers to the theory and practice of assessing, correcting, control-
ling, and preventing those factors in the environment that can potentially affect
adversely the health of present and future generations" (WHO, 1993a).
INTRODUCTION 7
Sometimes there is an ethical dilemma between promoting human health and
protecting the environment. One extreme position is that any control limiting
the exploitation of resources may inhibit an individual's or a community's at-
tempts to enhance their standard of living, therefore infringing on their rights
and freedoms as well as decreasing their ability to maintain health. At the other
extreme is the position that any action to protect the environment and maintain
the integrity of the ecosystem is justified regardless of the impact on human ac-
tivity and health. The United Nations has stated that ensuring human survival
should be taken as a first-order principle, one that takes precedence over all oth-
ers. The first order assigned to meeting human survival is consistent with the
United Nations Universal Declaration of Human Rights (UN, 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." Respect for nature and control of
environmental degradation is a "second-order" principle, which should guide all
human activities, except when these activities conflict with the first principle. In
reality, most such conflicts are more apparent than real and arise from a faulty
understanding of the human-environment interaction, or a dysfunctional social
and economic system.
Sustainable development implies that everyone eventually must have access to
the environmental resources that meet their needs. This must also be done with
a continuous commitment to improve general understanding of how the envi-
ronment and health are linked. It must be done without overwhelming the fi-
nite absorptive capacities of the global ecosystem.
Human Ability to Adapt

Human beings, like all living things, depend on their environments to meet their
health needs, including their needs for food, water, shelter, and security. Defi-
ciencies may happen because of inadequate resources, waste or an inequitable
distribution of these resources. When people are exposed to hostile or unsafe en-
vironments, microorganisms, toxins, excessive radiation, or armed enemies, their
health invariably suffers. Compared with most other species, however, humans
have extraordinary abilities to adapt to and influence their environment to meet
their needs. For example, people have learned to produce and gather food and
to limit their exposure to parasites and extreme weather conditions. They take
collective measures to protect themselves against hostile beings and adverse con-
ditions. They have also acquired practices (e.g., ethics, cultures) and structures
(e.g., cities, highways, dams) that enable them to better cope with the natural
environment.
While there are many ways to make the environment healthier, more often
than not, environmental health hazards are beyond the control of the affected
individual. This may be the case with the following conditions:
• industrial pollution
• poor services of drinking water and sanitation
• poor housing and town planning
• lax control over eating establishments or food industry

BOX 1.2
The Concept of Supportive Environments for Health
In the concept of supportive environments, determinants of the health of entire

populations are addressed, including the following:
• the role of local environmental factors in the healthy development of the com-
munity
• an approach that enables and promotes health, as well as protects from environ-
mental hazards
• creation of equity in health within a community
• the importance of sustainable development as a health issue
• people's understanding of environment in a broad sense
• people's sense of involvement and personal interest in restoring or creating a
healthy environment.
Source: Haglund et cii., 1992.
• poor quality roads

• poor conditions in the workplace.
Adaptation and change to improve a community's environment then require de-

cisions and actions by leaders of industry, government, and institutions. To
achieve this, decision makers may have to feel some community pressure, deci-
sion makers and their technical advisers may need better training, and resources
for environmental and health protection may have to be reallocated. The envi-
ronmental health professional is likely to be one person to whom the commu-
nity looks for advice on how to find solutions to their concerns, and to help em-
power them with increased capacity to understand the issues, consider the
options, and formulate action plans.
Supportive Environments for Health

Supportive environments are the conditions that countries or communities try to
create to achieve their health targets (see Box 1.2). The focus is on how good
environments enhance health rather than on the health impact of bad environ-
ments. This effort involves such practices as building healthy housing, promot-
ing healthy lifestyles, cleaning up industrial pollution, reducing traffic hazards,
reducing tobacco smoking, and changing dietary habits. In poor communities the
most important issues may be basic sanitation and water supply, improved ma-
ternal and child health care, and the control of communicable diseases.
The concept of empowering communities to take control over the determinants
of their health is indeed the key feature of health promotion. The WHO, in the now
much quoted Ottawa Charter (WHO, 1986) defined health promotion as "the
process of enabling people to increase control over, and to improve, their health."
INTRODUCTION 9
HISTORICAL PERSPECTIVE
Economic and Industrial Development and Environmental Health
While it is well known that biological agents and naturally occurring chemical and
physical hazards have existed throughout human history, there is also a long his-
tory of environmental pollution from anthropogenic sources (human activities).
Even in ancient times, sites of production and manufacturing were contaminated
with pollution. A good example is lead contamination in the area around smelters
centuries ago and the horrible odor and water pollution associated with tanneries.
By modern standards, the scale of most of these enterprises was very small, how-
ever. The technology was that of the individual artisan using traditional work prac-
tices that had not substantially changed for centuries. The resulting pollution was
usually restricted to the immediate area. Pollution from human waste was con-
sidered more of a problem, as it effectively limited the size of cities. As great a prob-
lem as pollution was occupational health and safety, as workers were subjected to
intense exposure to a variety of hazards at the workplace.
The Industrial Revolution marked a dramatic turning point in the interaction
between economic activity and the environment. Industrial pollution was first
identified as an obvious and serious issue in the early 1 800s, when it became ob-
vious that production on an industrial scale, using the breakthrough technology
of the time, resulted in pollution on a scale never before seen. This pollution was
largely the result of the energy requirements of a technology based on iron and
steel, which led to more widespread air pollution as well as local concentrations
of pollution near the factory site.
The United Kingdom, home of the Industrial Revolution, was the first coun-
try to suffer from industrial pollution on a massive scale. It became particularly
obvious during the later years of the reign of Queen Victoria (the Victorian era).
Mass production led to the recruitment of hundreds of thousands of new work-
ers into a wage-earning class. These workers soon became consumers themselves.
Production soared and the profits created a pool of capital that was then rein-
vested in further industrial expansion. The new industrial cities became infa-
mous. A well-studied example was the city of Manchester, but the export of new
technology created many other examples in the British Isles, Europe, and else-
where. At that time much of what is now the developing world was under colo-
nialism. It would be many years before these areas would suffer similar prob-
lems in the course of their own economic development. The colonial system
restricted most manufacturing to the colonizing country, which sold manufac-
tured goods in the colonies and bought raw materials and food from them.
Industrial pollution may have been a serious problem in the Victorian era,
but it was not high on the list of social priorities of the day. Considered much
more important at that time were social issues, such as child labor, class-based
poverty, alcohol and drug abuse (mostly gin and opium), welfare services (or the
absence thereof), corruption, and prostitution. All of these issues were related to
the urbanization that accompanied the recruitment of an industrial work force.
The principal health concerns of the day were communicable diseases, which
were out of control in the squalid, densely populated cities. These problems be-
came a national crisis in England and Scotland and it soon became obvious that

one reason for the crisis was that there was no effective local governmental re-
sponsibility for these problems.
The First Environmental Crisis
The first wave of sustained and broad-based environmental concern appeared in
Europe in the nineteenth century in response to serious public health problems
associated with adulterated food and water contamination. The primary threats
at the time were agents of infectious disease for the general public and disabling
and often fatal injury in the workplace. This increase in awareness, which led to
political action, came at a time of great social unrest and eventually reform. Child
labor, prostitution, alcohol and drug abuse, exploitative employment practices,
crime, and land ownership, which was concentrated in the hands of a few, often
absent landowners, were all part of the emerging big picture in Europe at the
time, particularly in economically developed countries such as England, Scotland,
France, the German states, and the Atistro-Hungarian Empire. A reform move-
rnent in the middle of the century tackled all of these problems with legislation
that was generally piecemeal and not always entirely effective. Together, these
reforms greatly reduced the magnitude of the problems but did not solve them.
In 1848 the British parliament passed the first broad-based public health law.
This was a significant event in the midst of a reform movement that reached all
sectors of urban life. Industrial pollution, however, was largely ignored at the
time. In part because the government saw its role as protecting the rights of fac-
tory owners, The Public Health Act concentrated on environmental problems of
a different type, namely clean water and health hazards related to infectious dis-
eases. The prevailing economic theory was that unconstrained economic growth
would benefit all levels of society and that maximal profits were needed to at-
tract investment. Another reason for neglecting the environment was that other
pressing social issues were so obvious and so severe that pollution seemed much
less important as an issue. At the time, there was essentially no public health sci-
ence that addressed chemical pollution, even though scientific understanding of
the health effects of toxic chemical exposures was relatively sophisticated. The
history of environmental pollution concerns and actions (see Box 1.3) is largely
a story of the issue of industrial pollution catching up with other public health
issues on the public agenda after first being neglected.
The intrinsic inefficiencies of Victorian technology ensured that pollution
would remain a problem until the early twentieth century, which was charac-
terized more by technological refinement than innovation. Applied chemistry and
chemical engineering expanded spectacularly in the late 1700s and early 1800s.
This led to the introduction of many processes that generated pollution, partic-
ularly in the production of sulphuric acid, soap, bleach, and soda ash (sodium
carbonate). Organic chemistry developed later and introduced many new syn-
thetic chemicals. However, in this era most of these chemicals were biodegrad-
able—i.e., eventually they could be broken down by natural processes in the en-
vironment. Chemicals that persisted for longer in the environment mostly came
later, except for metals such as lead.
Just before and during World War II, major advances in engineering and
chemistry substantially changed the face of industry, especially in the chemical
INTRODUCTION 11
sector. Synthetic rubbers, solvents, plastics, and pesticides became available and
were often more effective and cheaper to produce than the older products. Many
of these new synthetic chemicals were based on chlorine chemistry. A large num-
ber of them turned out to be difficult to break down by natural processes and,
as a result, persisted in the environment. Changes in technology and a greater
demand from consumers in North America, Japan, and Europe also led to huge
increases in the volume of hazardous materials. In the postwar years, production
expanded massively, along with a well-documented increase in industrial pollu-
tion that led to a public outcry in the 1960s and 70s in many countries.
The Second Wave of Environmental Concern

The second wave of public environmental concern, which came in the mid- to
late twentieth century, was dominated by two broad movements that came to-
gether into what was called the environmental or ecology movement. In the first
movement, which had its roots in the nineteenth century, conservation of nat-
ural resources and preservation of special sites of natural or historic significance
were important priorities. Until the mid-twentieth century its major achievement
was the designation in various countries of certain areas as parks, wilderness ar-
eas, and other protected lands. The second movement focused on substances that
could be toxic to humans or damaging to the environment. It grew in part out
of concerns at the turn of the century with food and drug adulteration; its great-
est achievement was food and drug safety laws, mostly in the early twentieth
century. The pure food and drug movement adopted environmental pollutants
as a central issue following the massive increase in production following World
War II. The new "toxics movement" was particularly inspired by the 1962 pub-
lication of the highly influential hook Silent Spring by Rachel Carson. Toxic ex-
posures that took place in the workplace were often much more intense than
those caused by emissions and effluents leaving the plant site. Unfortunately,
during this era, the environmental movement did very little directly toward im-
proving workers' health, as the two problems were not obviously linked at the
time. The issue of workers' health advanced more slowly, as part of the move-
ment to improve workers' rights.
These public movements, and the UN Conference on the Human Environ-
ment in 1972, persuaded many national governments to introduce legislation
that curbed industrial pollution, mostly by requiring companies to limit emis-
sions or effluents of pollution. This environmental movement peaked in the early
1970s, but it left a lasting framework of rcgulations, new technology, and poli-
cies aimed at preventing chemical pollution, particularly in the developed world.
Although not completely effective, these actions did substantially reduce the to-
tal amount of industrial pollution for a time and resulted in many examples of
successful environmental improvement. It would be an exaggeration to say that
the developed world solved the problem of industrial pollution or even reduced
it to acceptable levels, but the scale of the problem was significantly reduced.
The focus during this era was almost entirely on particular chemicals that
were relatively toxic. Omitted from the concern of the 1970s were carbon diox-
ide and relatively nontoxic chemicals such as the chlorofluorocarbons. These were
not generally understood to be serious environmental hazards until the late

BOX 1.3
Examples of Significant Events in Environmental
Health Concerns
1798 Thomas Maithus developed his theories on resource allocation and popula-
tion
1848 Public Health Act passed by British Parliament
1895 Svante Arrhenius describes the greenhouse effect
1899 First international convention to ban chemical weapons
1956 British Clean Air Act passed
1962 Publication of Rachel Carson's book Silent Spring draws attention to pesticides
and the environment
1969 First international agreement on cooperation in case of marine pollution
(North Sea region)
1972 United Nations Conference on Human Environment, Stockholm; DDT banned
in the United States
1982 Multilateral Conference on Acidification of the Environment starts process
leading to fornial recognition of transregional pollution and need for inter-
national controls
1986 First International Conference on Health Promotion; produced the Ottawa
Charter, which defined health promotion as enabling people to take control
of the determinants of their health.
1987 Our Common Future (the Brundtland Commission Report) calls for "sustain-
able development"; Montreal Protocol on limiting emissions to air of chioro-
fluorocarbons to reduce depletion of stratospheric ozone layer
1992 Earth Summit (United Nations Conference on Environment and Develop-
ment), Rio de Janeiro
1994 International Conference on Population and Development, Cairo
1995 UN World Summit for Social Development, Copenhagen
1996 UN Conference on Human Settlements (I-IABJTAT II), Istanbul
1997 UN Framework Convention on Climate Change, IKyoto
1980s, even though scientists had given warnings about their toxic effects much
earlier (see Box 1.3). These chemicals have since become a major environmen-
tal concern.
The Third Wave of Environmental Concern
In the 1980s and into the 1990s, the accelerated rate of economic development,
combined with a substantial increase in world population, introduced a critical
new factor into the environmental equation. Until the 1980s the levels of pro-
duction in the developing world were relatively low compared to those in the
developed countries. As a consequence, industrial pollution in developing coun-
tries tended to be confined to local areas, as it had been in Europe and America
in earlier times. Recently, however, production levels in these countries have in-
creased very rapidly along with the demand for goods and the capacity for di-
INTRODUCTION 13
Yect trading among countries because of the globalization of trade. Much of the
production in this new sector is relatively undercapitalized and therefore it is of-
ten based on expedient, cheaper technologies. There are usually few controls
over effluents and emissions, and the result is increases in industrial pollution.
Since 1987 and the publication of the seminal report Our Common Future
(WCED, 1987), environmental planning and economic development have be-
come oriented toward "sustainable development." the level of production and
activity that can be undertaken in one generation without compromising envi-
ronmental integrity or depleting the resources to support the next generation.
This concept, which is roughly equivalent to the idea in biology of living within
the carrying capacity of the ecosystem for a society, has entered the mainstream
of economic thought and environmental management. It represents a way of
thinking about development that takes into account resource management, pol-
lution, social development, and human health.
New environmental concerns continue to emerge. Some toxicologists are fo-
cusing on chemicals that disrupt the endocrine system and are persistent in the
environment (see Chapter 2). Certainly the concerns about global environmen-
tal change (see Chapter 11) have generated renewed interest in the environment
that will likely persist for decades to come.
C REQUIREMENTS FOR A HEALTHY ENVIRONMENT

Clean Air
Air is essential for life itself; without it we could survive only a few minutes. Air
pollution is one of the most serious environmental problems in societies at all
levels of economic development. As many as 500 million people are exposed
daily to high levels of indoor air pollution in the form of smoke from open fires
or pcorly designed stoves. More than 1 500 million people live in urban areas
with dangerously high levels of air pollution (WHO, 1992a). Industrial develop-
ment has been associated with the emission of large quantities of gaseous and
particulate substances from both industrial production and from burning fossil
fuels for energy and transportation. When technology was introduced to control
air pollution by reducing emissions of particles, it was found that the gaseous
emissions continued and caused problems of their own. Although current efforts
to control both particulate and gaseous emissions have been partially successful
in much of the developed world, there is recent evidence that air pollution is a
health risk even under these relatively favtrable conditions (WHO/NILU, 1996).
In rapidly developing societies, sufficient resources may not be initially in-
vested in air pollution control because of other economic and social priorities.
The rapid expansion of industry in these countries has occurred at the same time
as automobile and truck traffic has increased, demands for power for the home
have grown, and populations have concentrated in large urban areas, or mega-
cities. The result is some of the worst air pollution problems in the world.
In many traditional societies and in societies where household energy sources
considered to be clean are not yet widely available, air pollution is a serious prob-

1cm because inefficient and smoky fuels are used to heat buildings and to cook,
causing air pollution both outdoors and indoors. The result can be acute irrita-
tion of mucous membranes, respiratory infections, lung disease, eye problems,
and increased risk of cancer. Women and children in poor communities in de-
veloping countries are particularly exposed to air pollution.
The quality of air indoors is also a problem in many developed countries be-
cause buildings have been built to be airtight and energy efficient. Chemicals pro-
duced by heating and cooling systems, smoking, and evaporation from building
materials accumulate indoors and create a pollution problem.
Safe and Sufficient Water

Water is essential to life. We need to drink a minimum of 1 to 2 liters per day.
After about 4 days without water, a person will die. Water is also essential for
plants, animals, and agriculture, so throughout history, people have clustered
along the shores of lakes and rivers to get water for households and agriculture.
Water also provides natural transportation, is used for disposal of wastes, and
plays an essential role in the farming, fishing, and industrial sectors. Although
fresh water is considered a renewable resource, there is a limited supply. More-
over, it is unequally distributed among the countries and people of the world. In
many regions, shortages of fresh water are the main obstacle to agricultural and
industrial production. In some cases this has led to difficult conflicts (e.g., the
difficulties of sharing water resources among the countries of the Middle East).
These shortages lead to poverty and soil degradation; many cities and agricul-
tural regions are drawing water from underground aquifers faster than these
sources are able to replenish themselves.
The quality of fresh water is of great importance to maintaining good health.
A high proportion of life- and health-threatening infections are transmitted through
contaminated water or food; as much as 80% of all sickness and disease in some
developing countries has been attributed to the lack of safe water and appropriate
means to dispose of excrement (WHO, 1992a). Nearly half the world's population
suffers from diseases associated with insufficient or contaminated water, which af-
fect mostly the poor in virtually all developing countries. Two thousand million
people are at risk of waterborne and foodborne diarrheal diseases, which are the
main cause of nearly four million child deaths each year. Cholera epidemics, which
are also frequently transmitted by unsafe drinking water, are increasing in fre-
quency. Schistosomiasis (200 million people infected) and dracunculiasis (10 mil-
lion people infected) are two of the most serious water-based diseases. Insect vec-
tors breeding in water transmit other life-threatening diseases such as malaria (267
million infected), filariasis (90 million infected), onchocerciasis (18 million in-
fected), and dengue fever (30 to 60 million infected) (WHO, 1992a).
Water shortages usually lead to problems of water quality, since sewage, in-
dustrial effluent, and agricultural and urban runoff overload the capacity of wa-
ter bodies to break down biodegradable waste and to dilute noribiodegradable
waste. Water pollution is most serious in cities where controls on industrial emis-
sions are not enforced and sewers, drains, and sewage treatment plants are of-
ten lacking.
INTRODUCTION 15
Adequate and Safe Food
Food provides the energy for our bodies to function. The equivalent of about
1000 to 2000 calories is required each day for a person to stay alive, depending
on a person's body weight and level of physical activity. Without food, most pco-
pie would die after about 4 weeks. Food also provides essential vitamins and trace
elements, without which people develop deficiency diseases.
The output of the world's food-producing systems has matched the population
growth over the last few decades (Fig. 1.3). There is no global shortage of food or
lack of capacity to produce it at this time. Nonetheless, the success in global agri-
culture has not been shared equally. Asia and Latin America have substantially in-
creased their per-capita food production, while Africa's food production has not
kept pace with population growth, and the countries of the former Soviet Union
have had a dramatic decrease in fod production. For a large part of the world's
population, undernutrition and the infections associated with it remain a major
cause of ill health and premature death. Foodborne pathogens cause millions of
cases of diarrheal disease each year, including thousands in the developed world.
Poor food distribution and its utilization are the main culprits in this situation.
Rapid degradation of land and watcr resources also pose an important threat to
future food production. To make matters worse, because of economic pressures to
develop exports of agricultural products, increasingly, the best land is not being
used for local food production. In many situations, food intake is the most impor-
tant route of exposure for chemical environmental contaminants.
There are many health effects, other than foodborne diseases, that result from
an inadequate diet, including starvation under disaster conditions, excess num-
bers of premature and underweight births, and nutrition so marginal as to weaken
immune systems and deny millions of children proper growth and development.
Food contaminated by toxins from plants and molds or those present in fish and
shellfish can also be a serious problem, as is food contaminated directly by agri-
180
Agricultural -
6' 160 production
140
— Population
120
0)
'T 100
CD per capita
80
60
a)
C)
40
20
0 -
1970 1975 1980 1985 1990 1995
Year
Figure 1.3 Trends in world food production and food production per capita. From WHO,
1997, with permission.

cultural chemical residues or indirectly through pollution of the soil by toxic met-
als and solvents.
Safe and Peaceful Settlements
A safe and peaceful place in which to live is also necessary for good health. In-
adequate housing and community infrastructure other structures adversely af-
fect the health of urban residents. Low income, uncertain employment, insecure
residential tenure, and poor health go hand in hand with inadequate, over-
crowded shelter lacking space and sanitation and with minimal health protec-
tion. Residents are exposed to disease pathogens, pollutants, violence, and injury
hazards, often in conditions that breed alienation and psychi social dysfunction.
Drug abuse, family break-up, urban violence and suicide are believed to be as-
sociated with overcrowded housing and inadequate community support. Over-
crowding enables the spread of acute respiratory infections, tuberculosis, menin-
gitis, and intestinal parasites; infants, children, and the elderly are at particular
risk as a result of less developed or reduced resistance. Injuries from burns or
scalds are also associated with overcrowding, as it is more difficult to safely store
hazardous household substances such as bleach or kerosene.
In urban areas of developing countries, a high proportion of housing is con-
centrated in informal settlements made of flammable materials and often built
on dangerous sites. Disasters such as mudslides, floods, and hurricanes are par-
ticularly destructive in these crowded, inadequately prepared communities. Fear
of eviction is also a constant worry for most tenants and inhabitants of these set-
tlements. As these settlements usually have only rudimentary water supply sys-
tems and no sewers or drains, risk of infection associated with excreta is always
high. An estimated 30% to 50% of the solid wastes generated in urban areas of
developing countries is left uncollected (WHO, 1992c).
War and civil violence are also major factors in disrupting housing and threat-
ening well-being, as, demonstrated in Somalia, Rwanda, and Bosnia Herze-
govina.
Stable Global Environment
Human health and ecosystem health are inextricably linked. The long-range
transport of air pollutants, the transboundary movement of hazardous products
and wastes, stratospheric ozone depletion, climate change, and loss of biodivcr-
sity are among the global problems threatening the health of many communi-
ties (WHO, 1997). For example, when sulphur and nitrogen oxides are emitted
from fossil fuel power plants, they are transported over long distances, often
across national boundaries, and are converted to acids that eventually fall to the
ground as acid rain or snow. Individuals' health may be affected by acidified wa-
ter used and treated in water supplies, since it contains higher water concentra-
tions of metals (e.g., copper and lead from pipes, or aluminium and mercury
from soil and sediments). Also, the stratosphere's ozone layer is being damaged
by various chemicals, including chlorofluorocarhons used in refrigeration. Dam-
age of the ozone layer leads to increased ultraviolet radiation exposure to large
populations, which in turn may cause eye cataracts, skin cancer, and other prob-
lems. Finally, the greenhouse effect, emissions of carbon dioxide and other green-
INTRODUCTION 17
house gases, and eventual global warming (McMichael et al., 1996) may also
threaten a stable global environment that protects health.
The United Nations Environmental Programme (UNEP) launched the Global
Environmental Project in 1995, a participatory process involving experts from
over 100 countries. Its recent publication, GEO-2000 (UNEP, 2000) noted that
global emissions of CO 2 continue to rise, with an annual increase over the past
decade of 1.3%, with the level in 1996 being almost four the 1950 total. GEO-
2000 urges that alternative policies be swiftly implemented to avoid major envi-
ronmental disasters.
MEASURING ENVIRONMENTAL QUALITY,

HuMAN EXPOSURE, AND HEALTH IMPACT
Measuring Environmental Quality

The measurement of environmental hazards, levels of human exposure to these
environmental hazards, and the resulting health impact are clearly interrelated.
Specifically, the investigation of environmentally induced health effects always
requires consideration of the nature of the hazard and levels of exposure. Even
though it is pertinent to evaluate the extent of environmental change within the
discipline of environmental health, however, the main purpose of this book is to
focus on evaluating human exposure and health impact.
In many countries, measurements of pollutants in air, water, food, and some-
times soil have become routine. Most of the common measurements are made
because of health concerns, but some relate to the agricultural or industrial use
of the air, water, or soil. Examples of common measurements are sulphur diox-
ide (SO 2 ) and total suspended particulates (TSP) in air, which indicate the ex-
tent of pollution from coal use, diesel oil use, and specific industries (e.g., ce-
ment factories). Another common measurement is the concentration of
Escherichia co/i (E. co/i) bacteria in water. This gives a good indication of the fecal
contamination of the water and the extent to which the water can be used for
drinking, bathing, or food processing. In certain dry areas of the world, well wa-
ter can have very high natural concentrations of toxic metals, e.g., arsenic, and
routine monitoring is necessary.
There is an important distinction between environmental quality monitoring
and human exposure monitoring. The latter takes into account whether the pol-
luted air has actually been inhaled, the polluted water has been drunk, and the
polluted food has been eaten. In addition, human exposure monitoring takes into
account the length of time a person spends in the polluted area and the amounts
of pollutant that are consumed. In many countries, an occupational health in-
spector periodically monitors the quality of the workplace environment. During
such surveys, hazardous exposures as well as safety and ergonomic aspects are
taken into account.
Measuring Human Exposure to Environmental Hazards

The measurement or estimation of levels of exposure to an environmental pol-
lutant or hazard is called exposure assessment. Human exposure can occur through

several routes—most importantly, inhalation, ingestion, and skin contact. As-
sessment can be undertaken by a direct approach, an indirect approach, or a com-
bination of the two. With the direct approach, pollutant concentrations taken in
by an individual through food, water, air, or skin contact are measured directly.
Field studies using personal monitors, questionnaires, and diaries provide the ex-
posure data. Survey sampling techniques are used to select a sample of people
that statistically represents the population of interest. Also, several reliable marker
methods have been developed to estimate environmental exposures, e.g., blood
lead levels can be used to estimate exposure to from all sources.
The indirect approach uses a mathematical model to estimate exposure. In-
formation about how much time people spend in different environments (such
as in their homes, workplaces, motor vehicles) is combined with data on pollu-
tant concentrations in these microenvironments to estimate human exposure to
airborne contaminants. Similarly, keeping diaries of food and beverage con-
sumption can be invaluable when combined with data on contaminant levels
and food and beverage products to estimate ingestion exposures.
Determining Health Effects and Risks in Human Populations

A health effect is the specific damage to health that an environmental hazard can
cause in an individual person. Often the same hazard can cause a range of dif-
ferent effects of different severity. Traditional diagnostic tools can determine ef-
fects in the individual. The science of carrying out such health measurements in
populations is called epidemiology, which is delined as "the study of the distribu-
tion and determinants of health-related states or events in specified populations,
and the application of this study to the control of health problems" (Last, 1995).
This definition highlights the fact that epidemiologists are concerned not only
with death and disease but also with more positive health states and with the
means to improve health.
The initial step in any epidemiological investigation involves the description
of the problem at hand. A clear case definition, or definition of the health effect
of concern (e.g., respiratory disease in children living in an area with air pollu-
tion), has to he established so as not to confuse investigators. Similarly, if the
study is triggered by a pollution or exposure situation, the exposure type needs
to be clearly defined. Describing case distributions by time, place, and person is
usually an extremely useful first step in providing clues for the cause of the dis-
ease and any environmental factors involved (Beaglehole et al., 1993). There are
two approaches to quantifying the number of cases occurring: measures of new
cases (incidence) or of existing cases (prevalence). Incidence can only be measured
within a defined time period (for acute infectious disease, incidence is often mea-
sured in days or weeks, whereas for chronic diseases it is often measured in
years). Prevalence can only be measured at a specific point in time or over a rel-
atively short defined period (called period prevalence).
Once a case definition has been established, it is important to define the pop-
ulation at risk of exposure and of developing the outcome of interest, to avoid
counting people not at risk and thereby diluting the evaluation. The population
at risk may be defined by factors such as age, gender, area, workplace, occupa-
tion, or ethnic group. Definitions of populations at risk become more difficult in
INTRODUCTION 19
situations where the illness of interest is chronic in nature, is indistinguishable
from normally endemic illnesses, or involves long latency periods. In such settings,
disease rates may need to he studied in relatively large population units (countries,
provinces) over extended periods of time. After defining the cases and the popu-
lation at risk, the number of cases and persons at risk can be used to calculate rates
of disease occurrence (either as incidence rates or prevalence rates). The observed
incidence (or prevalence) of the disease must be compared with disease occurrence
in some reference (or control) population, with appropriate adjustments so that
rates are compared using equivalent populations distributed by age, gender, and
other similar aspects and according to similar case definitions. In this manner, in-
vestigators can determine whether there is indeed an increase in the health effects
of concern and can gather information to isolate what might have caused it.
Environmental Health Monitoring
To quantify health effects by monitoring the health of populations, appropriate
health indicators must be selected, monitoring methods must be developed, and
data quality needs to be evaluated. Through standardization of health indicators and
harmonization of sampling and measurement techniques, it is possible to compare
data between jurisdictions. Health-monitoring strategies involve the application of
different methods to get results in the most cost-effective way (see Table 11).
Monitoring strategies are dependent on available health care infrastructure.
Use of records from hospital and medical services is more feasible in countries
with national medical care services and centralized administrations than in coun-
tries where most services are provided by independent health care agencies and
TABLE 1.1
CHARACTERISTICS OF SELECTED APPROACHES TO HEALTH MONITORING
Sample Population Data Providers Potential for Quantification
of Environmental Impact
National Entire population Health care personnel Large, provided that health
registers of country Hospital records data are ]inked with good
Laboratory records exposure data; confounding
needs to be avoided
Local Entire population Health care personnel Large, provided that health
registries of smaller Hospital records data are linked with good
administrative Laboratory records exposure data; conclusions
entities can be generalized only if
the population studied is
representative
Sentinel Population Selected praciitioners, Only if relevant exposure data
networks covered by laboratories, hospitals are concurrently collected
data providers and the population studied
is representative
Periodic ideally randomly Specifically trained survey Only if relevant exposure data
health drawn from team are concurrently collected or
surveys population are available from other
sources

TABLE 1.2
USEFUL HEALTH INDICATORS
Physical Health Psychosocial Well-being
PUBLIC
Respiratory effects Changes in the quality of Ide

Injuries Changes in cultural/social patterns
Comnsunicahle diseases Rates of crime
Cancer Rates of drug and substance abuse
Effects on ferlility and development e.g., congenital Stress-related conditions
anomalies
WORKERS
Injuries Changes in the quality of life

Days off work Relocation
Long term activity limitations Stress-related conditions
Respiratory effects
Noise effects
Dermatitis
Effects on fertility and development
Cancer
private organizations. Surveys in which representative sampling strategies are

used may provide a more realistic alternative in some situations. Each country
has to develop its own strategy for health monitoring. Priority should be given
to monitoring health and environmental variables that have (a) the greatest im-
pact on the health of the population, and (b) the highest potential for preven-
tion. Also to be considered is whether there is a strong commitment to intervene
with preventive measures.
The types of information and indicators that may he used to assess the po-
tential impacts of environmental exposures on physical and psychosocial health
in both the general public and the workforce are listed in Table 1.2. These indi-
cators of occupational or public health can be combined with those for biologi-
cal monitoring (see Chapter 3) and environmental monitoring to describe the
environmental health status of a population. Environmental health indicators are
being incorporated into many environmental programs. Guidelines for the use
of these indicators are provided in Linkage Methods for Environmental Health Analy-
sis (Briggs et al., 1996), and are discussed further in World Resources 1998-99: A
Guide to the Global Environment (WRI, 1998) a joint publication by the WRI, the
United Nations Environment Programme (UNEP), the United Nations Develop-
ment Programme (UNDP) and the World Bank.
PATTERNS OF ILLNESS THROUGHOUT THE WORLD
Demographic and Epidemiological Transitions

Over the last two centuries, a major shift in the health situation of most countries
has taken place. In Europe, high mortality and high birth rates with people suffer-
ing from a variety of communicable diseases, have given way to a low-mortality,
INTRODUCTION 21
low–birth rate situation in which few cases of communicable diseases have occurred.
This shift, which started in the last century and has continued to the present time,
has been called the demographic transition (see Fig. 1.4), as it relates mainly to the
crude birth rate and death rate. When both rates were high, the populations stayed
stable. In those countries where they are now both low, the populations have again
stayed stable, as in the Scandinavian countries. During the transition from high to
low rates there is a period when death rates lower while the birth rate stays high;
during this period the population will grow. The more the death rates decrease
while birth rates remain stable, the more rapid is the growth of the population, a
phenomenon that can be found in most developing countries. Many developed
countries have more or less completed their demographic transition. The death rate
in such countries now principally reflects diseases associated with aging.
The high pretransition death rates are very much linked to a high level of
communicable disease, so the transition in death and birth rates is accompanied
by a change in the pattern of the causes of death—less communicable disease
and more chronic noncommunicable disease. This change in disease pattern over
time has been called the epidemiological transition. Figure 1.5 shows how the mor-
tality patterns changed in the United States in the twentieth century.
This pattern of change has been shown in all countries to follow economic
development, as improvements in housing, sanitation, and community infra-
structure reduce the risk of communicable disease. It is not just the improving
economy itself that protects citizens' health but the improvements to water sup-
ply, shelter, and nutrition, which are part of the development of community ser-
vices. As these improvements take place, chronic noncommunicable diseases be-
come a more important factor, largely because of the longer life expectancy and
increasing proportion of old people in communities.
C
0
Cu
75a- Stage 1 Stage 2 Stage 3
0
a.
0
0
0
lit 40
a- ——
a) Population
- (absolute
.0 30 numbers)
a)
'O - Birth rate
'O
(a
20
el
10
a)
'O
sj
14
50 - 100
Time (years)
Figure 1.4 The demographic transition. From Kjellstriirn and Rosenstock, 1990, with per-
mission.

100
MM
0
E 60
(U
0
0
U)
C)
CU 40
U)
0
U)
0
0
1900 1910 1920 1930 1940 1950 1960 1970
Year
Figure 1.5 The epidemiological transition as it has occurred in the United States. From
Beaglehole et al., 1993, with permission.
Mortality Trends
In many developing countries crude death rates are declining while in developed
regions they remain steady. The data on life expectancy, which are a better mea-
sure of trends, as it takes into consideration differences in age structure, show
that improvements in levels of health have been made throughout the world, al-
though life expectancies are still much lower in developing countries than in de-
veloped regions.
Age-standardized mortality figures are generally riot available for developing
countries. Table 1.3 provides estimates of the proportion of deaths from various
causes as a percentage of the total number of deaths. Although this gives a pro-
file of what people in each country are dying of, it does not indicate which groups
are dying at what age or at what rate. The differences between the two patterns
shown in Table 1.3 reflect in part a different age composition in the two groups
of ciuntries. But this difference does not go far to explain the 10-fold disparity
in mortality from infectious diseases in general or the 20-fold difference in
mortality from tuberculosis. Such statistics are dramatic evidence of the pretran-
sinorl state of the developing world.
As an unambiguous event, death is a good indicator for statistical compar-
isons of health situations in countries. Mortality rates, nonetheless have their
limitations. They tell us little about suffering and loss of productivity related to
morbidity; direct information on the incidence and prevalence of diseases would
INTRODUCTION 23
TABLE_1.3
CAUSES OF DEATH IN DEVELOPED AND DEVELOPING COUNTRIES, 1993
Deaths from all Causes (%)
Cause of Death Developed Countries Developing Countries
Infectious and parasitic diseases 1.2 41.5
Chronic lower respiratory diseases 7.8 5.0
Malignant neoplasms 21.6 8.9
Diseases of the circulatory system 46.7 10.7
Maternal causes 0 1.3
Perinatal and neonatal conditions 0.7 7.9
External causes of mortality 7.5 7.9
Other and unknown causes 14.5 16.8
Source: WI-tO, t995a
be a better indicator. But this information is only available from surveys of lim-
ited temporal and geographic scope. Systems for registering cases of important
communicable diseases, such as AIDS, yellow fever, leprosy, and cholera, exist
in most countries. Annual data on cancer incidence are reported to the Interna-
tional Agency for Research on Cancer (IARC) from participating countries'
registries.
At an individual level, the risk (%) of dying between the ages of 15 and 60
years from noncommunicable disease does not increase during the epidemiologic
transition, it decreases (see Fig. 1.6). These transitions are also accompanied by
a change in the types of environmental hazards to which people are exposed. In
the pretransition stage, the dominant hazards are what we know to be the tra-
ditional hazards of poverty: unsafe drinking water, lack of sanitation, poor shel-
ter, indoor air pollution from stoves and fireplaces, and injury hazards from poorly
constructed buildings. As economic development and the epidemiologic transi-
(I)
- - —
15 Non-communicable
C) diseases
o 10 Communicable
diseases
Injuries
Oh-
1955 1960 1965 1970 1975 1980 1985
Year
Figure 1.6 The epidemiological transition as it has occurred in Chile. From Murray et al.,

tion progress, the hazards of the modern age start to dominate: air pollution from
power stations, industry, and cars; water pollution from industry; and agricul-
tural chemical exposures. The term health hazard transition has been coined to de-
scribe this change in types of environmental hazards (Kjellström and Rosenstock,
1990). All of these concepts are useful in describing the change that occurs in
conjunction with economic and community development.
Murray and Lopez (1996), using different estimates of the world's largest
killers from those used by the WHO, concluded that noncommuni able diseases,
rather than infectious diseases, are the world's top killers, accounting for 56%
of all deaths; infectious diseases account for 34% and injuries for 10°/s. While
stressing that there is a lot of error in estimates, their assessment suggests that
developing countries are further along in the transition than previously expected.
Burden of Disease
Many conditions that do not lead to people's deaths are still responsible for a high
prevalence of illness or disability. Burden of disease measures the impact of ill health
on communities (World Bank, 1993; Murray and Lopez, 1996; the term public
health impact was used previously). Included in this concept is the impact of both
morbidity and mortality on normal life and work capacity. Often the unit of cal-
culation is in terms of life years lost, which statistically converts the duration and
timing of illness and disability into a comparable scale, equivalent to the years that
might have been lost from a fatal disease. Insurance companies apply the same ap-
proach when calculating compensation for permanent injury, e.g., 25% of death
compensation for the loss of a limb, 50% compensation for blindness, etc.
Attempts have been made to express the burden of disease in a single num-
ber, namely the overall life-years-lost equivalent. This number has been given
different names, such as quality-adjusted life years (QALYs) or disa bility- adjusted life
years (DALYs). Each is based on a number of very uncertain assumptions and
judgments about how a disease or disability period should be translated into
number of disease free or disability free years lost prior to death. Thus, the final
numbers need to be interpreted with caution. Although it is convenient to have
a single number for burden of discasc, ii may be misleading, particularly when
comparing disease patterns over time or between geographic regions, for which
the impact of disease on well-being and productivity is not constant. For exam-
ple, improved rehabilitation, technologies for mobility, and access policies have
made physical disabilities much less of a handicap in some countries than they
used to he. To assume that a particular type of disability is equivalent to a par-
ticular number of life-years-lost in every country at any time may seriously bias
the interpretation of what these calculations mean.
The burden of disease can also be described as a series (or matrix) of num-
bers of mortality, morbidity, and disability. Although this description is more
complex than using just one number, it offers the opportunity to highlight spe-
cific aspects of the burden, such as the impact on the use of health services. A
"burden of disease matrix" would also make it possible to better identify the con-
tributions to this burden of disease from specific environmental hazards, with-
out the need to translate ill health into death. For instance, it has been estimated
in Sweden that about 400,000 people are disturbed in their homes by traffic noise
INTRODUCTION 25
BOX 1.4
The Disability-Adjusted Life Year Concept
To show how the calculations have been made for one specific example of burden
of disease measurement, the DALY concept will he described here. The WHO and
the World Bank undertook a joint exercise to attempt to quantify the extent of
"healthy life" lost due to various diseases and conditions. Diseases were classified
into 109 categories on the basis of the international classification of diseases (ninth
revision). Using the recorded cause of death where available and expert judgment
when records were not available, the study assigned all deaths in 1990 to these cat -
egories by age, gender, and demographic region. For each death, the number of
years of life lost was defined as a difference between the actual age at death and
the expectation of life at that age in a low-mortality population. The disability, and
the incidence of cases by age, gender, and geographic region were estimated on the
basis of community surveys or expert opinion. The number of years of healthy life
lost was then obtained by multiplying the expected duration of the condition by a
severity weight that measured the severity of the disability in comparison with loss
of life. Diseases were grouped into six classes of severity or disability. The death and
disability losses were then combined. As shown in Figure 1.7, the value of each year
of life lost, shown on the left, rises steeply from 0 at birth to a peak at age 25 and
then declines gradually with increasing age. The age weights reflected a consensus
judgment, but other patterns could he used. Through using the combination of dis-
counting (reducing by 3% SC) that future use of healthy life is valued at progres-
sively lower levels) and age weights (e.g., using uniform age weight, with each year
of life having the same value, therefore increasing the relative importance of child-
hood diseases), a pattern of DALYS lost by death at each age could be seen. As shown
on the right, the death of a newborn girl represents a loss of 32.5 DALYs; a female
death at age 30 means the loss of 29 DALYs; and a female death at age 60 repre-
sents 12 lost DALYs.
Source: World Bank, 1993.
and about 100 people die from lung cancer due to residential radon exposure in
their homes. Is it possible to make a comparison of the health impact of noise
disturbance and death with a common measurement unit? Would that be needed
to guide decisions about financial input into prevention of different health risks?
The methods for the measurement of the burden of disease (discussed further in
Box 1.4) will need further development to produce useful information for deci-
sion making and priority setting for environmental hazards control. Two of the
key issues are whether deaths in the future should be discounted using an eco-
nomic analysis approach, and whether deaths at different ages should be given
different values (Fig. 1.7). Considerable work is now being done to atfempt to
quantify the value of reducing health risks (Tengs et at. 1999) using economic
methods such as contingent valuation, and comparing the results using various
techniques (Spiegel, 2000). This type of analysis may be very useful for decision-
makers.

a)
Value of a year of life DALYs lost by death at given year (females)
U)
a) >-
1.6 -J 40
Ca 0
a) 0,
1.2 am 30
0
ca
a)
>, 0
ca 0.8 20
0 U)
a) 0
Ca
0.4 • 10
a)
>
Ca
a)
0
0 10 20 30 40 50 60 70 80 90 0 10 20 30 40 50 60 70 80 90
Age x Age at death in years
Figure 1.7 Age patterns of age value weights and disability adjusted life years (DAlY) lost.
From World Bank, 1993, with permission.
The sum of disease across all ages, conditions, and regions is referred to as
the global burden of disease (GBD). Table 1.4 shows the GBD by cause and regional
burden of disease in four of the eight World Bank regions.
Vulnerable Groups
By far the greatest risk factor for poor health is poverty. Particularly vulnerable
groups include children, women, elderly people, racial minorities, disabled peo-
plc, and indigenous peoples, all of whom are often vulnerable because they are
not empowered to change their Physical environments. Smaller body size, pre-
existing diseases, pregnancy, and nutritional deficiencies are several factors that
may also increase their vulnerability. Often we do not know how specific haz-
ards affect subgroups of the population. The effects of the hazard on groups in
populations that are in a minority or underrepresented in detailed studies may
not be identified. There may also be subgroups that are more vulnerable because
of where they live or work, because of personal illness (e.g., asthma), or because
of biological factors of susceptibility as described below. (As noted in Chapter 3,
levels of safe exposure to a contaminant for the general population are often ad-
justed to account for these vulnerable groups.)
Children As much as two-thirds of all preventable diseases due to environmen-

tal conditions occurs in children (WHO, 1997). Children are physically more vul-
nerable to environmental hazards than adults for several reasons. The metabolic
processes of children are different from those of adults (Bearer, 1995). Children
under the age of 5 are particularly susceptible because the liver's detoxification
potential and kidney's filtration potential is not fully developed (WRI, 2000). Also,
their bodies are still developing and the effect of an environmental insult can in-
terfere with that development. The investigation of how toxins may affect fetal
and child development is called developmental toxicoloqv. Lead, for example, causes
damage to the growing central nervous system in children. The metabolic rate per
kilogram of body weight of children is much higher than that of an adult, in part
because children are still developing and they are smaller. This means that their
INTRODUCTION 27
TABLE 1.4
GLOBAL DISTRIBUTION OF DALY-LOSS BY DISEASE, 1990A
Latin Formerly
America Socialist Established
Sub-Saha ran and the Economies Market
Cause World Africa Caribbean of Europe Economies
Population 5267 510 444 346 796
iiiillious)
cOMMUNICABLE ) 45.8 71.3 42.2 8.6 9.7

DISEASES (/1
TubeRulosis 3.4 4.7 2.5 0.6 0.2

STDs and IIIV 3.8 8.8 1.2 1.2 3.4
Diarrhoea 7.3 10.4 5.7 0.4 0.3
Vaccine preventable 5.0 9.6 1.6
Ifl [cOlons
Malaria 2.6 10.8 0.4 <0.05 <0.05
Respiratory inlections 9.0 10.8 6.2 2.6 2.6
Maternal causes 2.2 2.7 1.7 0.8 0.6
Perinatal causes 7.3 7.1 9.1 2.4 2.2
Other 5.3 6.4 8.3 0.6 0.5
NONCOMMUNICAI3LE 42.2 19.4 42.8 74.8 78.4

DISEASES (%)
Canrer 5.8 1.5 5.2 14.8 19.1

Nutritional defuiencies 3.9 2.8 4.6 1.4 1.7
Neuropsychiatrk disease 6.8 3.3 8.0 11.1 15.0
(;ercbrovasctilar disease 3.2 1.5 2.6 8.9 5.3
lschemic heart disease 3.1 0.4 2.7 1 3.7 10.0
Other 19.3 9.9 19.8 25.0 27.3
INJURIES ¼) 11.9 9.3 15.0 16.6 11.9
Motor vhicic 2.3 1.3 5.7 3.7 3.5

Intentional 3.7 4.2 4.3 4.8 4.0
Other 5.9 3.9 540 8.1 4.3
TOTAL I '¼ I 100.0 100.0 100.0 100.0 100.0

Millions ol DALYs 1 362 293 103 58 94
DALYs per 1000 259 575 233 168 117
population
''Examples are of four of the eight A'ortd Bank regions. HIV, hiinoiii ininulnodeficicuc)' Irus: STEs, sexuall
transmitted disease.
S( in rc C: World Bank, 1993,
respiratory rate, for example, is proportionately greater and they breathe in much
more air pollution in relation to their body weight than an adult in similar cir-
cumstances. Children also have a grealer chance of experiencing chronic effects
of exposure to environmental hazards than adults, because when they are ex-
posed to a carcinogen, the chances are mitch higher that they will live beyond
the latency period (the years that it takes for a cancer to develop after exposure).
The physical environment of children is dillerent from those of adults, even
in the same home. Newborns remain in cribs and are not able to remove them-

selves from environmental hazards such as direct sunlight. They ITiust count on
adults to recognize and deal with dangerous environments. Toddlers live close
to the ground and thus may be exposed to contaminants in soil and dust. They
are constantly putting things in their mouths, as young children go through a
phase of intense oral exploratory behavior, and they may be prone to pica, the
practice of eating dirt.
Children are also vulnerable in a social sense. When families are not strong
and poverty is severe, children are often exploited and deprived of their rights.
Children are less able to protect themselves by making informed choices, protest-
ing working conditions, or refusing to be exposed to hazards. In some countries,
children are forced to work in hazardous environments to earn money to sup-
port themselves and their families. Under such conditions, which can amount to
slavery, children have no protection and may be severely abused. When they are
injured, there may be no one to support them or to replace their lost income. In
extreme situations, children have been forced into prostitution where they ex-
perience a high risk of becoming infected with human immunodeficiency virus
(HIV). It is estimated that there are over 20 million "street children" in Latin
America alone. Child abuse and parental neglect contribute to childhood injuries
and poisoning by drugs and other chemicals.
A child's environment also plays a significant role in the prcpagation of in-
fectious diseases. Despite successes in tackling vaccine-preventable diseases, each
year 2.8 million children die from them and a further 3 million suffer ill health
as a result of these diseases (WHO, 1993b). Certain diseases are more prevalent
in children (for example, asthma), and high concentrations of toxicant (for ex-
ample, air pollution) will affect children before they affect adults. Many children
are born prematurely, grow up in poverty, or do not have adequate nutrition.
These conditions in turn decrease their ability to cope with an environmental
hazard. One-third of children in developing countries weigh less than 2.5 kg at
birth, and almost half the children in Africa show signs of malnutrition. There
are numerous biological, chemical, and physical agents that, at low doses, have
little effect on a mother but have profound effects, such as congenital and de-
velopinental problenis, on the fetus. Listeria, methyl mercury, and radiation are
prime examples of such agents.
Recognizing the vulnerability of children, the Ministers of Enviroiiment of the
seven highly developed countries and Russia published the 1997 Declaration of the
Environment Leaders of the Fight on children's Environmental Health (USEPA, 1997).
The declaration highlights the problems of specific hazards, such as polluted wa-
ter, air quality, lead, endocrine-disrupting chemicals, and environmental tobacco
smoke, along with the general problem of appropriate risk assessment and stan-
dard setting, which must take into account the special situations of children.
Women The rapid increase in problems arising from the destruction of natural
resources, rapid industrialization and urbanization, pollution and population pres-
sures has a special impact on women (Sims, 1994). Women have less privileged
status in society and less access to resources, although they are often obliged to
fulfil multiple roles and function as producers, reproducers, and home managers.
Of the 1.3 billion people living in poverty, 70% are women (UNDP, 1995).
INTRODUCTION 29
Women may be at a disadvantage from birth onward because of inadequate
nutrition, lack of education, heavy workloads, early marriage, and early and fre-
quent pregnancies. In some countries, women who have no partners are at par-
ticularly high risk of poor health and are forced into poverty or prostitution be-
cause of insufficient opportunities to earn a living by themselves. Prostitution has
grown to immense proportions in some developing countries (this applies to girls
and boys as well as women). In addition, women suffer discrimination at the
workplace and are often subjected to the worst working conditions. In rural ar-
eas, women have particularly heavy workloads, as they are responsible for gath-
ering fuel, collecting water, and foraging.
Women's vulnerability during pregnancy and childbirth is evident from the
very high levels of maternal mortality in most developing countries. In many low-
income communities, there is a significantly higher incidence of certain diseases
among women, because they spend more time in its contaminated environments.
Women suffer more from diseases associated with inadequate water and sanita-
tiori and from respiratory problems associated with smoke in living environments
where cooking or heating is on open fires or poorly designed stoves using coal
or wood. An anthology entitled Women, Health and the Environment (Sims, 1994),
published by the WHO, provides further examples and details in this area. The
role of women in sustainable development has received increasing attention. In
many societies, women have greater influence than men on rates of population
growth, infant mortality, and various aspects of health and environmental degra-
dation. Thus any socioeconomic pressures that are detrimental to women are
detrimental to society as a whole and the global ecosystem.
im
a)
-
> • :
: . •. -
a)
Ca
0
Ca
E0
4
a)
0
••
U)
. ••. •
IQ 2
. . . .
0 I I I I I
0 10 20 30 40 50 60 70 80 90 100
Percent of adult females who are literate
Figure 1.8 Fertility rate by female literacy, 1990. From WRI, 1994, with permission.

Women spend more time than men doing both paid and unpaid work in
almost all developing and developed countries. Although more women are
working outside the household than ever before, their wages still lag behind
those of men. Many women work in low-paying jobs in the service sector and
in the informal sector, for example, in food vending and trading in household
goods, tailoring, domestic service, and artisanship. Women also contribute sig-
nificantly to agricultural production and they traditionally harvest forest prod-
ucts, such as firewood, in many countries. Women usually hear primary re-
sponsibility for collecting, supplying, and managing water. In addition, women
deliver basic health care in many parts of the world. Even so, in many soci-
eties, cultural and religious attitudes have resulted in discriminatory laws and/or
practices that have prevented women from becoming equal partners in society.
In almost all areas of the world, the literacy rate for women is luwer than that
for men.
Women's poverty, limited education, and economic opportunities and dis-
crimination contribute to high fertility rates, which in turn lead to various prob-
lerns, including strained resources and endangered health for women and chil-
dren. The World Bank has shown that for every year of schooling a woman
receives, her fertility rate is reduced by IO% and for every 1-3 years of school-
ing, child mortality rates are reduced by 1 5% (World Bank, 1993). The rela-
tionship between female literacy and fertility is shown in Figure 1.8; Figure 1.9
shows the relationship between child tiiortality and female literacy.
Education and training program for women have become a high priority in
efforts to move toward sustainable development. These programs must, of course,
350
'so I U
. 1
250 I
-U
() U
U
2 200 U •
U I U
U •u
ci) . S
C. • .
U
.0
150 . •1
.
'a
• •. U
U
we U •
I
•
•
I
I U
U
. U
• I U
•. U
U
50 U
I.
•
U
•
U.S •••
• a
løI I I
0 10 20 30 40 50 60 70 80 90 100
Percent of adult females who are literate
Figure 1.9 Mortality rate for children under 5 by female literacy, 1990-91. From WRI,
INTRODUCTION 31
be combined with basic health services, expanded economic opportumties, and
enforced civil rights. Many multilateral organizations, including many United Na-
tions agencies, have been working together to recommend national and inter-
national actions toward these ends. One publication by the United Nations Pop-
ulation Fund, published as part of Investing in Women: The Focus of the '90's (Nafis,
1990), urges governments and international nongovernmental organisations to
do the following:
• document and publicize women's vital contribution to development

• increase women's productivity and remove barriers to productive resources
• provide family planning and improve the health of women
• expand education
• establish equality of opportunity.
Elderly People The world is aging. This simple fact has immense implications for
the provision of shelter, health care, and social support. Elderly persons are at
an increased risk of having diseases. They are more likely to be malnourished
than younger adults, for a variety of social, economic, and physiological reasons
(including early dementia), and are therefore more vulnerable to many diseases.
Especially important are diseases that decrease the body's ability to cope with
hazardous exposures. Examples of such disabling conditions that are common in
the elderly include emphysema, kidney disease, congestive heart failure, de-
mentia, and diabetes. As with children, elderly persons with respiratory diseases
are not able to tolerate air pollution. The elderly are more likely to have had a
long exposure to a given toxin simply because they have been living longer. An
older body also has less mass, and often metabolizes toxins at a slower rate. As
in children, therefore, smaller doses of a given substance will have a greater ef-
fect on the elderly than on younger adults.
Recent rapid changes in lifestyles in many societies has led to changes in cul-
tures that once had more respect for elders. As a result, the elderly are often im-
poverished without the social support of extended families, and are subject to
some of the same patterns of vulnerabilities as children.
Disabled People It is estimated that there are 500 million disabled people in the
world today, and this number is expected to double in the early part of the
twenty-first century. Four out of five disabled people live in developing coun-
tries, and one third of them are children. Few countries are able to provide mean-
ingful assistance, support, rehabilitation, and protection, thus many disabled peo-
ple are particularly impoverished and subject to exploitation and chronic illness.
Chronic psychiatric conditions, including addictions to alcohol or drugs, may also
lead to malnutrition, self-mutilation, and depression. These conditions may de-
crease the body's ability to cope with environmental hazards.
Disabled people often have difficulty finding meaningful jibs that pay them
an adequate living. They are often forced to take unwanted and dangerous jobs
or face unemployment and poverty. The disabled, therefore, are sometimes at
increased risk from environmental hazards because of their cultural milieu, in
addition to their vulnerability as a result of their disability.

Indigenous Peoples In general, throughout the twentieth century the state of
health of aboriginal peoples has remained far worse than that in populations of
non-aboriginal origin in the same countries. For instance, infant mortality rates
remain at a persistently higher level in aboriginal people in Canada (Fig. 1.10).
In the early 1990s the infant mortality rate among registered Canadian Indians
was still about twice as high as the national rate (Fig. 1.11), despite the gains
made during the post—World War II years, particularly among Northwest Terri-
tories Inuit. The success of immunization programs in Canada substantially re-
duced the impact of such diseases as measles, rubella, mumps, poliomyelitis,
tetanus, and diphtheria in aboriginal communities. Similarly, the availability of
effective anti-tuberculosis therapy and the large scale control efforts of the 1950s
resulted in a steep decline in tuberculosis mortality. Despite such improvements,
the disparity between aboriginal and nonaboriginal Canadians remains great, with
the former having an incidence of tuberculosis as much as ten times higher.
Within Inuit of one region of the Northwest Territories, the incidence of
meningitis was 20 times higher among 5-year-olds, and 33 times higher among
infants, compared to nonaboriginal communities (Hammond et al., 1988). While
diarrheal diseases are less severe in Canadian aboriginal communities than in
many developing countries, isolated outbreaks continue to be reported, high-
lighting the similarity between conditions experienced by Canada's aboriginal
communities and that of many developing countries. Similarly, infections of the
180
1I.
.(/1 140
120
0
(I)
80
a)
C
60
40
Olt
Countries
Figure 1.10 Infant mortality rates in different countries and aniong aboriginal populations
in Canada. A, most sub-Saharan African countries, Afghanistan, Bangladesh, Haiti; B,
some North African countries, India, Central America, Brazil; C, Venezuela, Argentina,
China, some Asian and Middle Eastern countries; D, Korea, Malaysia, Chile, Panama,
Uruguay, Romania, former USSR; E, Costa Rica, Cuba, Jamaica, Greece, Portugal, East-
ern Europe; F, Western Europe, North America, Australiasia, tsrael, Japan, Hong Kong.
From Waldram et al., 1995, with permission.
INTRODUCTION 33
250
200
\ NWT Inuit
\
.0 \
cc
150 \
cc
cc \
100
\
Registered \
Indians N
49
ce
Figure 1.11 Infant mortality
rate among Canadian registered
Canadians Indians, Northwest Territories
Inuit, and all Canadians. From
1956-601961-65 1966-70 1971-5 1976-80 1981-5 1986-90
Waidram et al., 1995, with per-
Year 1IIiSSiO11.
respiratory tract are more common among aboriginal communities. Various hous-
ing surveys have documented the high proportion of aboriginal dwellings char -
acterized by overcrowding, inadequate heating, and poor ventilation (Clatwor-
thy and Stevens, 1987). These factors contribute to the high risk of respiratory
infections.
Of particular concern is the increase in chronic diseases and the high preva-
lence of obesity in many aboriginal groups. Among the most serious health prob-
lems now affecting aboriginal peoples are injuries sustained as a result of acci-
dents and violence. The high level of morbidity and mortality from such injuries
has been attributed to the prevailing economic conditions and social stress that
aboriginal peoples experience. For example, in Canadian aboriginal communities
a high number of residential tires have occurred, which have been linked to per-
sonal behaviors such as smoking, drinking, leaving children unattended, and hav-
ing suicidal intent. Contributing social environmental factors that are largely at-
tributable to poverty include disconnection of electricity because the utility bill
hasn't been paid, alcoholism, lack of fire protection in the community, mrnad-
herence to building codes, lack of child care, and mental health problems. More-
over, acts of violence are intimately related to the mental health of individuals
and the social health of a community. Suicide, which is particularly high among
young adult males, is indicative of the alienation and despair occurring in these
corn mun i ties.
Many aboriginal people recognize that these problems must be resolved
through a healing process undertaken by the communities themselves. The
reestablishment of individual and community self-esteem has been actively pur-
sued through the enhancement of positive traditional values and customs. A land-
mark conference entitled "Healing Our Spirit Worldwide" in Edmonton, Canada
in 1992 brought together aboriginal groups from around the world who shared
their experience in healing the wounds of violence and substance abuse. Such

efforts, combined with the general move toward self-government, promise en-
couraging results. There is great benefit to be gained when environmental health
professionals work with traditional healers who know the community and are
often highly trusted SO they can be effective agents of change.
IMPACT OF ENVIRONMENTAL FACTORS ON HEALTFI

It is clear that the environment in which people live has a huge influence on
their health. A safe water supply, food that is nutritionally sufficient, and inter-
ruption of the fecal–oral chain of disease transmission are essential to reducing
the incidence of gastrointestinal diseases. Because of such simple measures, these
diseases had already declined significantly in most of Europe and North Amer-
ica well before the introduction of therapeutic drugs and oral rehydration ther-
apy. Likewise, immunization and the use of modern drugs have contributed to
the dramatic decrease in mortality from infectious respiratory diseases. Reduc-
tions in overcrowding and overall improvements in housing and the working en-
vironment have also played a major role. Whereas noncommunicable disease
risks have decreased through reduced air pollution in large cities of developed
countries, the effect of other exposures, such as tobacco smoking, continue to
pose major health risks.
The sharp increase in the incidence of lung cancer and the steady decrease in
stomach cancer stand out as the most significant changes in cancer trends, the
former being due mostly to past trends in tobacco smoking, the latter possibly to
changes in the preservalion of food and the amount of fruit and vegetables in
the diet. It is not possible to accurately assess the burden of cancer attributed to
environmental factors except for that related to occupational exposure to car-
cinogens (e.g., to asbestos, vinyl chloride, or henzene), urinary schistosomiasis,
(related to stagnant water from dams, for example) which carries a high risk of
bladder cancer, or hepatitis B virus (e.g., from improperly disposed needles),
which is associated with a high incidence of liver cancer. The most significant
cancer risk factors for the general population are tobacco smoking, alcohol con-
sumption, dietary composition, and sexual behavior. The role of ionizing radia-
tion in inducing cancers is also well established but forms only a small percent-
age of total incidcnce. Exposure to the ultraviolet component of sunlight is
responsible for a significant number of skin cancers—much more so than ioniz-
ing radiation. Perhaps 5 % of all cancers in the general population is due to ex-
posure to environmental chemicals. The variety of chemicals produced, used in
daily life, and released to the environment is rising, and exposure to them is of
increasing concern.
Table 1.5 shows an estimate of the GBD from selected environmental threats
in 1990 and potential worldwide reductions through environmental interven-
tions (World Bank, 1993). It is estimated that 36 million DALYs, or 3% of the
GBD, are preventable with currently available and feasible interventions in the
workplace environment. Additional interventions are likely to become available
in the future. These losses are caused by injuries and deaths in high-risk occu-
pations and by chronic illness stemming from exposure to toxic chemicals, noise,
stress, and physically disabling work patterns. If by removing urban air pollution
INTRODUCTION 35
TABLE 1.5
ESTIMATED GLOBAL BURDEN OF DISEASE FROM SELECTED ENVIRONMENTAL
THREATS, 1990, AND POTENTIAL WORLDWIDE REDUCTIONS THROUGH
INTERVENTION IN THE WORKPLACE AND AMBIENT ENVIRONMENT
Reduction Burden Averted
Achievable by Feasible Burden
Type of Burden from Through Interventions Averted
Environment These Diseases Feasible (millions of per 1000
and Principal (millions of Interven tions b DALYs/year) Population
Related Diseases° DALYs/year) (%) year) (DALYs/year
OCCUPATIONAL 318 - 36 7.1
Cancers 79 5 4 0.8
Neuropsychiatric 93 5 5 0.9
Chronic respiratory 47 5 2 0.5
Musculoskeletal 18 50 9 1.8
Unintentional injury 81' 20 16 3.1
URBAN OUTDOOR AIR
Acute respiratory
infections 123 5 6 1.2
Chronic respiratory
diseases 47 5 2 0.5
ROAD TRANSPORT
(motor vehicle injuries) 32 20 6 1.2
All the above 473 - 50 10.0

The diseases shown are those for which there is substantial evidence of a relationship with the environment.
Estimates are derived from the product of the efficacy of the interventions and the proportion of the global
burden of disease that occurs among the exposed.
'Cotnputed by subtracting motor vehicle inJuries (32 million DALYs) from all unintentional injuries (113 mil-
lion DALYs
tAdj itsted for double counting. However, this is based on current allocation of economic resources; much more
could be achieved with a different p rioritization for resource use
Source: W,,rld Hank, 1993.
5% of all acute respiratory infectious and chronic respiratory diseases could be

prevented, this would result in a decrease in a burden by 8 million DALYs each
year, or 0.6% of the GBD (Table 1.5).
Local environmental impacts on especially vulnerable groups may be much
greater. For example, airborne lead concentrations have been high in polluted
urban environments where lead has come mainly from the exhaust of vehicles
burning leaded gasoline. Elevated lead levels in children have been associated
with in3paired neuropsychological development, poor intellectual performance,
and behavioral difficulties.
Diseases related to poor sanitation and inadequate water supply, inadequate
garbage disposal and drainage, heavy indoor air pollution, and crowding proba-
bly account for nearly 30% of the tolal burden of disease (see Table 1.6). Mod-
est improvements in household environments would avert almost one-quarter
of this burden, mostly as a result of reductions in diarrhea and respiratory in-
fection s.

TABLE 1.6
ESTIMATED BURDEN OF DISEASE FROM POOR HOUSEHOLD ENVIRONMENTS
IN DEVELOPING COUNTRIES, 1990, AND POTENTiAL REDUCTION THROUGH
INTERVENTIONS
Burden
Principal from These Reduction Burden
Diseases Diseases in Achievable Averted Burden
Related Developing Through by Feasible Averted
to Poor Relevant Countries Feasible Interventions per 1000
Household Environmental (millions of Interventions (millions of Population
Environments0 Problem DALI's/year) %)b DALI's/year) (DAL I's/year)
Tuberculosis Crowding 46 10 5 1.2
Diarrhea Sanitation, 99 40 40 9.7
water sUpply,
hygiene
Trachoma Water supply, 3 30 2 0.3
hygiene
Tropical Sanitation, 8 30 2 0.5
cluster't garbage
disposal,
vector
breeding
around
the house
Intestinal Sanitation, 18 40 7 1.7
worms water supply,
hygiene
Respiratory Indoor air 119 15 18 4.4
inlections pollution,
crowding
Chronic Indoor air 41 15 6 1.5
respiratory pollution
diseases
Respiratory Indoor air 4 10 0.1
tract cancers pollution
All of 338 79 19.4
the above
Note The demographically developing group consists of the demographic regions Sub-Saharan Atrica, India,
China, oilier Asian countries, Latin America, the Caribbean, and the Middle Eastern ,,rcsccrtt.
The diseases tisled are those for which there is smibsta ntial evidence of a relationship with the household. I Lx-
a mp!es of cxci tided conditions are violence retatcd to c rmtwding and guinea wornt intection rela ted to poor waler
supply I
'Estimates are derived Iroto the products of the efficacy of the interventions and the proportiott of tile btir-
den of disease that occurs itnong the c\posed.
Includes diarrhoea, dysentery, cholera, and typhoid.
' 1 Diseases within the tropical cltmster tttost affecteif by the domestic cnvtrontttcttt are sdnstosotttiasis, Si uttt
American trypanosotttiasis, and Baticroftian fitari,isis.

Lcss than one.
Source: Wortd Batik, 1993.
In a review of the links between development, environment, and health

(WHO, 1997), the "environmental fraction" of the global DALY's for major dis-
ease and injury groups ranged between 10% and 90% (Table 1.7). The result-
ing approximate estimate of the environmental contribution to the global bur-
den of disease and injury was 23% (WHO, 1997).
INTRODUCTION 37
TABLE 1.7
PROPORTION OF GLOBAL DALYS ASSOCIATED WITH ENVIRONMENTAL
EXPOSURES, 1990
% of all DALI's
Global Environmental
DALYs Environmental DALYs All Age Age 0-14
(thousands) fraction (%) (thousands) Groups Years
Acute respiratory 116,696 60 70,017 5.0 4.50
infections
Diarrheal diseases 99,633 90 89,670 6.5 6.10
Vaccine-preventable 71,173 10 7117 0.5 0.49
infections
Tuberculosis 38,426 10 3843 0.3 0.04
Malaria 31,706 90 28,535 2.1 1.80
Unintentional injuries 152,188 30 45,656 3.3 1.60
Intentional injuries 56.459 NE NE
Mental health 144,950 10 14.495 1.1 0.08
Cardiovascular 133.236 10 13,324 1.0 0.12
diseases
Cancer 70,513 25 17,628 1.3 0.11
Chronic respiratory 60.370 50 30,185 2.2 0.57
diseases
Total these diseases 975,350 33 320,470 23.0 15.40
Other diseases 403,888 NE NE
Total all diseases 1,379,238 23) (320,470)
NE, to It est mat ed
Source; WHO, 1997; DALY data front Miirrar and Lopez. 1996
LINKS BETWEEN ENVIRONMENTAL AND

OCCUPATIONAL HEALTH
Importance of the Workforce

The workforce of a country is the backbone of its development. A healthy, well-
trained, and motivated workforce increases productivity and generates wealth that
is necessary for the good health of the community at large. Injured and sick work-
ers, quite apart from being a major source of morbidity to themselves and their fam-
ilies, affect the economy as a whole, as do Thst workdays due to illness and injury.
The environment in the workplace generally involves levels of higher human ex-
posure to environmental hazards and more injuries than in the residential envi-
ronment. Every year approximately 100 million work injuries and 200.000 occu-
pational deaths are reported in addition to the millions of cases of illnesses due to
chronic exposure to noise, infectious agents, biomechanical hazards, and toxic chem-
icals. The workforce therefore requires particular health protection to maintain pro-
ductivity, social equity, and personal security. The Encyclopaedia of Occupational Health
and Safety (ILO, 1998) is a good source of information about workers' health.
Linked Environmental and Occupational Health Hazards

The main reason for linking the occupational and general environments when
addressing health concerns is that the source of the hazard is often the same. A

common approach may work effectively in varied settings, particularly when it
comes to the choice of chemical technologies for production. One example is the
use of water-based paints instead of paints containing potentially toxic organic
solvents. Another example is choosing nonchcmical over chemical pest control
methods.
Substituting one substance for another that is less acutely toxic may make
good occupational health sense. However, if the new substance is not biodegrad-
able or if it damages the stratospheric ozone layer, it is not an appropriate ex-
posure control solution; it only moves the problem elsewhere. Chiorofluorocar-
hins (CFC5), widely used as refrigerant instead of the more acutely dangerous
substance, ammonia, is the classic example of what is now known to have been
an environmentally inappropriate substitution, for CFC5 are the main cause of
damage to the stratospheric ozone layer (see Chapter 11, Ozone Depletion and
Ultraviolet Radiation).
Common Approaches and Human Resources

The scientific knowledge and trair1ing required to assess and control environ-
mental health hazards are generally the same skills and knowledge required to
address health hazards within the workplace. Toxicology, epidemiology, occupa-
tional hygiene, ergonomics, and safety engineering are basic sciences that un-
derlie assessment in these two fields. It thus may make good sense for the same
professions to monitor both areas, especially in countries with scarce resources
(see Role of the Environmental Health Professionals, below).
The Workplace as a Sentinel for Environmental Hazards

Environmental health hazards have often been first identified from observations
of adverse health effects in workers. The workplace is where the impact of in-
dustrial exposures is best understood. To conduct an epidemiological study it is
necessary to define the exposed population, the nature and level of the expo-
sure, and the specific health effect. It is generally easier to define the members
of a workforce than it is to determine the membership of a community, partic-
ularly in a community that is transient. As well, the outcome of high levels of
exposure typical of the workforce are almost always easier to delineate than more
subtle changes attributable to low-level exposure.
Information on occupational health effects of many toxic exposures (includ-
ing metals such as lead, mercury, arsenic, and nickel, as well as known carcino-
gens such as asbestos) has been used to calculate the health risk to the wider
community. For example, as early as 1942, reports began to appear of cases of
osteomalacia with multiple fractures among workers exposed to cadmium in a
French factory producing alkaline batteries. During the 1950s and 1960s, cad-
mium intoxication was considered to be strictly an occupational disease. How-
ever, from the knowledge gained about the workplace came the recognition that
the osteomalacia and kidney disease that was occurring in Japan at this time,
"ltai itai" disease, was due to cadmium contamination of rice from irrigation wa-
ter containing cadmium from a mine and metal refinery. Research in occupa-
tional epidemiology made a substantive contribution to the understanding and
recognition of the environmental health effects.
INTRODUCTION 39
The Total Exposure Concept
It is not cnough to assess the exposure to a hazard from just one source. The sum
of all exposures needs to he measured to assess health impacts and establish dose-
response relationships. Pesticide exposure is a classic example where occupational
exposure may he supplemented by substantive environmental exposure. This may
come through food and water source contamination and through nonoccupational
airborne exposure. In Central America, for example, some cotton growers using pes-
ticides not only have little access to protective clothing but live very close to the cot-
ton fields; many live in temporary housing with no walls for protection from aerial
pesticide spraying. Workers also wash in irrigation channels containing pesticide
residues, resulting in increased exposure (Michaels et al., 1985). Thus to understand
the relationship between their pesticide exposure and the health effects that may
be reported, all sources of exposure to pesticide should be taken into consideration.
Other examples of exposure that may occur at the workplace as well as in the am-
bient environment are exposure to particulate matter from engine emissions (from
industrial machines or traffic), benzene (as a solvent or from cigarette smoke), and
polycyclic aromatic hydrocarbons (from products containing tar or from diet).
Consistency in Setting Standards

Environmental health standards are usually much stricter than occupational
health standards, as shown, for example, by the guideline values recommended
by the WI-lO for selected chemicals for each exposure situation given in Table
1.8. The rationale for the difference is that the community includes many sub-
groups that are relatively sensitive, including the very old, the ill, young chil-
dren, and pregnant women, whereas the vork1orce is at least healthy enough to
work. Also, it is often argued that risk is more "acceptable" to a work force, as
these people are benefiting by having a job and are therefore more willing to ac-
cept the risk. Many ethical and scientific debates rage around the question of
standards and their degree of protection and for whom. Linking occupational and
environmental health can be a positive contribution to sorting out these contro-
versies. In this regard, tightening the connection between occupational and en-
vironniental health may facilitate greater consistency in setting standards.
TABLE 1.8
COMPARISON BETWEEN WHO HEALTH-BASED GUIDELINES FOR AIR
IN THE WORKPLACE AND IN THE GENERAL ENVIRONMENT (WHO AIR
QUALITY GUIDELINES)
Chemical Workplace Guideline General Environment Guideline
,ug/m 3 (8-hr mean) ,ag/m 3 (annual mean)
Lead 30-60 0.5-1.0
Cadmium 10 0.01-0.02
Manganese 300 1
Mercury 50 1
Formaldehyde 500 100 (24 hours)
Nitrogen dioxide 900 150 (24 hours)
Sulfur dioxide 1300 50
Source: WHO, 1 987a and several Technical Report Series issues

Incentives for Prevention
Although the workplace is usually the site of more intense exposures, the im-
pact of these hazards on the general public has often been a major force in stim-
ulating cleanup efforts, both inside the workplace and in the surrounding com-
munity. For example, the discovery of high levels of lead in workers' blood by
an industrial hygienist in a lead loundry in Bahia, Brazil led to investigations of
lead in the blood of children in nearby residential areas (Nogueira, 1987). The
finding that the children had high lead levels was a major impetus in the com-
pany to take action to reduce occupational exposures as well as lead emissions
from the factory, although workers in the foundry are still exposed to substan-
tially higher exposures than would be tolerated by the general community. For
more about the relationship between occupational and environmental health,
see the section by Yassi and Kjellström in the Encyclopaedia of Occupational Health
and Safety (ILO, 1998).
OBSTACLES TO AND OPPORTUNITIES FOR RESOLVING

ENVIRONMENTAL HEALTH PROBLEMS
Demographic Issues
The impact of people on the environment is related to the size of the population
and to the level of consumption. Both expand independently and both lead to
increasing pressure on the environment as both a supplier of resources and a
repository of waste. Limited resources have made development in the poorest
countries of the world difficult, with increasing demand for water, food, and en-
ergy for domestic use being in direct proportion to the number of users. Mean-
while, more people are moving to urban areas where the infrastructures are rarely
able to keep up with the influx of new citizens. In temperate and sub-Arctic
countries, energy needs may be greater than in other parts of the world because
of the climate. Countries in these areas are generally highly developed, and the
high level of consumption accompanying their affluence (which until recently,
in many countries, was not accompanied by much genuine concern for the
environment or the need br conservation of resources) has magnified global
problems
Different areas of the world have different rates of population growth. The
global annual increase is thought to have stabilized, with an increase of about
81 million people added each year for 1990-95 (WRI, 2000). Nevertheless, the
world population, which was 5.3 billion in 1990, and more 5.9 billion in 1999
is expected to be between 7.7 and 11.2 billion by the year 2050 (WRI, 2000).
Because of the dillerences in rates of increase, the proportion of the world's pop-
ulation in North America and Europe has been shrinking while in other parts of
the world it has been expanding or has remained stable (see Fig. 1.12). These
projections are based on expected trends in birth and death rates, and adjust-
ments to the projections will he necessary as new information becomes available.
Improvements in the provision of health care may alter the pattern of mortality,
and the AIDS pandemic will have a major influence on population growth, es-
pecially in Africa, where children and young adults are most affected. Changes
INTRODUCTION 41
10
7 -
Figure 1.12 World popula-

6 1b • tion trends and projections.
><
,• -.
C , least developed coun-
0 5 ,
.01 I.- tries, medium variant; - - -

0 4 -••• ••-'•- developing countries,
0
0 medium variant; - - - de-
3 veloped countries, medium
variant; - - - world pop-
2
ulation, low variant, ..........
World population, high vari-
ant; - - - - - - world popula-
0 1 1 I I tion, medium variant. From
1950 1960 1970 1980 1990 2000 2010 2020 2030 WHO, 1 992a, with permis-
Year sion.
in lifestyle, such as in reproductive and dietary habits, age at marriage, or to-

bacco, alcohol, and drug consumption, may also alter population projections.
However, the single most important factor influencing the rate of population
growth is the education of women.
Rapid growth in urban population has been evident in most countries for over
10 years. This has important implications for health and the environment. The
concentration of people and economic production in urban areas brings many
ccst advantages in waste management. The per-capita cost of piped water, many
kinds of sanitation, education, health care, and other services is likely to be less
in some concentrated populations. Growing urban populations may also stimu-
late agricultural development and reduce the irillux from rural populations. Ur-
ban growth, however, usually brings substantial health and environmental prob-
lems, especially for poorer groups. Without effective governmental policies, the
potential advantages of urbanization may be outstripped by the many disadvan-
tages.
The size, rate of growth, and age distribution of a population is only part of the
demographic problem of a country or region. Movement of populations across bor-
ders also constitutes a major component of a demographic pattern. Migrants are
usually driven by economic need toward countries where there is a greater po-
tential for employment or the possibility of opening up new land. Increasingly, po-
litical refugees have contributed to migratory movements. Ecological change, such
as drought, has also forced migration. While the total number of migrants repre-
sents a small fraction of the world's population, these people can have a major in-
fluence on the resources and structure of the host population, especially when
unanticipated environmental or political events cause a large number of people to
move to a neighboring country. These migrants are often confronted with severe
health and environmental problems and seldom have access to basic health ser-
vices and health insurance coverage. Their living conditions are usually inferior to
those of the host population, resulting in a negative effect on their health.

Poverty
Poverty has been defined by the World Bank as the inability of an individual or
household to attain a miniirial standard of living. The level of prosperity in a
country and the distribution of resources within it determine the level and na-
ture of poverty. The association between poverty and health is strong and obvi-
ous. The poor usually have much lower life expectancy, higher infant mortality,
and a higher incidence of disability. They suffer more from communicable dis-
eases and a high proportion of their lives is spent in poor health.
The number of poor people in a given country is estimated from the number
of people with incomes below a level defined as the poverty line. The World
Bank estimates that in 1985 there were 1115 million people living below the
poverty line, defined as $370 U.S. per person per year, or U.S. $1 per person per
day. The extreme poverty line is set at $275 U.S. per person per year and there
were 634 million people living at that level in the world in 1985 (see Table 1.9).
Defining poverty solely by level of personal income, however, cannot ade-
quately represent all aspects of health. Also, setting a single international poverty
line based on income per capita can be misleading since it cannot take sufficient
account of differences between countries and the income needed to attain an ad-
equate living standard. Furthermore, variations in living costs between areas
TABLE 1.9
WORLD BANK ESTIMATES OF THE SCALE OF POVERTY 4 IN DEVELOPING
COUNTRIES, 1985
Net
Under-S Primaiy
Head- Mortalityd School
Number of count Poverty (per Life Enrollment
Poor Index b Gapc thousand Expectancy Rate
(millions) (%) (%) born) (years) (%)
Sub-Saharan 180 47 Il 196 50 56
Africa
East Asia 280 20 1 96 67 96
China 210 20 3 58 69 93
South Asia 520 51 10 172 56 74
India 420 55 12 199 57 81
Eastern Europe 6 8 5 23 71 90
East em 60 31 2 148 61 75
Mediterranean
and North Africa
Latin America 70 19 1 75 66 92
and the
Can hbcan
All developing 1116 33 3 121 62 83
countries
The poverty tine in international dolls rs (using Pu rctasing power parities) is $370 per capita a year for the
poor.
The headcount index is defined as the percentage of the poputation below the poverty line
The poverty gap is defined as the aggregate rncnme shortfall of the poor as a percentage of aggregate con-
sUrnption
Undcr —5 mortality rates are for I 980--85, e\ccpt for Chmna and South Asia, where the period is 1975-80.
Source: World Bank, 1990.
INTRODUCTION 43
within countries are such that some people with income well above the poverty
line may have inadequate living standards while someone living below the
poverty line may have adequate standards.
A better way of calculating the number of people living in poverty is to eval-
uate the number that lack a minimum standard of living including adequate food,
safe and sufficient supplies of water, secure shelter, access to education and health
care, and, in high-density settlements, provision for the removal of domestic
wastes. With these criteria it has been estimated that 2200 million people live in
poverty in the developing world. According to the United Nations Development
Program (UNDP) 1300 million live in absolute poverty. 840 million are under-
nourished (UNDP. 1997); 1400 million lack safe drinking water (UNICEF, 1997)
and 900 million are illiterate (UNESCO, 1996), as discussed by the World Re-
sources Institute (WRI, 2000).
In most cities in developing countries, between one-third and two-thirds of
all inhabitants live in informal settlements with inadequate or no infrastructure
or services. Even in the richest countries, a proportion of the population suffers
the adverse health effects of physical deprivation and social exclusion. Particular
cities or districts within cities that suffer most have not only high levels of
unemployment, particularly among young people, but also high levels of poor-
quality housing and social problems. They also tend to have significantly higher
than average infant mortality rates and a lower life expectancy.
At the beginning of the chapter the overall increase in life expectancy was
noted. But the gap in life expectancy between the least developed (43 years) and
most developed (78 years) countries is widening; by the year 2000 the gap is
projected to be 37 years. Also, even if improvements are made globally, chang-
ing conditions could result in dramatic setbacks in specific countries. The most
striking example is the reduction in life expectancy in Russia following 1990
(WRI, 1996).
Consumption Patterns
One important obstacle to progress in resolving environmental health prchlems
is the major difference in consumption patterns between different countries and
between different groups within countries. The very high consumption of energy
and natural resources by the richest countries and the richest groups within coun-
tries cannot be sustained. If the people of China achieved the same density of au-
tomobiles per capita as that in the United States, for example, the production of
greenhouse gases, air pollution, and other traffic-related problems would create a
major health crisis. Greenhouse gases also vastly increase the global problem of
climate change (see Chapter 11, Climate Change and the Greenhouse Effect).
Rees and Wackernagel (1992) characterized the land area necessary to sus-
lain current levels of resource consumption and waste discharge by a population
as its ecolog wal footprint. The ecological footprints of high income cities are hun-
dreds of times larger than their politic or geographical area and are much larger
than the ecological footprints of lower income communities.
Development is often seen as the poor reaching toward the lifestyle and eco-
nomic level of the rich. Clearly, large gaps in health and well-being between pop-

ulation groups and countries are not equitable, but should the aim of develop-
ment he for future generations to copy the rich? Or rather should it be to find a
healthy and sustainable level of economic development? The challenge is for each
scciety and the global community to establish limits of consumption that will
make it possible to provide for the basic needs of all people, without sacrificing
opportunities for persona] improvements in lifestyle.
Technological innovations offer hope for expansion of "the good life" to every-
body. Improvements in fuel efficiency of cars and the development of catalytic
converters for pollution control are examples of such innovations. Electric cars
may provide the next threshold of technological advance in relation to cars; how-
ever, the root problem lies in transport systems that encourage people to use cars
instead of more cost-efficient and pollution-avoiding alternatives. information
technology may reduce the need for travel. Perhaps a whole new energy-efficient
approach to living and working will develop.
Macroeconomic Policies
Macroeconomic policies have important direct and indirect effects on health and
the environment. They influence the use and degradation of natural resources
because they can affect consumer demand and the prices of natural resources.
The effect of macroeconomic policies are felt most directly at the level of an in-
dividual's purchasing power. For example, they permit improvements in the qual-
ity and quantity of food and thus in nutritional status and susceptibility to dis-
ease. in an economic crisis, they may result in sharply diminished purchasing
power and a lack of adequate nutrition.
Global economic changes, adverse changes in the terms of trade for Some
countries, and an increased debt burden driven by the rise of real interest rates
have all contributed to periodic decline in the word economy. The International
Monetary Fund (IMF) has required many countries to implement "structural ad-
justment programs" (usually cuts in public expenditures, including health and
related services) before it provides loans to developing countries. Public works
such as piped water supplies, sewers, and drains, which require a large capital
investment, often receive the largest cuts. For example, in sub-Saharan Africa
the social services budget fell by 26% between 1980 and 1985 and in Latin Amer-
ica by 18%. Health spending per person has declined in most countries Since
1980. Most experts recognize that there may be adverse effects on nutrition and
health. However, there is much uncertainty about the actual impact, and it is
generally acknowledged that structural adjustment may adversely affect the en-
vironment and health.
Despite this pessimistic picture, there have been shorter periods of real growth,
such as 1995-1998. The effect of macroeconomic policies cannot he considered
in isolation. Trends in the global economy may also dictate personal income and
what is possible for a country to attempt to do with macroeconomic policies. It
should he kept in mind, however, that countries with better health status have
more equitable social policies (Kawachi ci a]., 1999). It is not wealth per se but
the distribution of prosperity in the society that seems to he the link between
health and the social environment (Hertzman et a]., 1994).
INTRODUCTION 45
ROLE OF THE ENVIRO1"MFNTAT. HEAlTH PRflFFSS1CNAT
You Can Make A Difference

Confronted with all these problems and challenges, it is easy to despair over how
little one professional can do to improve things. But there are gocd reasons for
optimism. There are solutions to most, if not all, of these problems. This book
can guide the reader toward such solutions. The role of environmental health
professionals is to apply their knowledge and experience to help the coinnmnity
understand the environmental health hazards they face and to analyze the tech-
nical and social approaches to reducing or eliminating human exp sure to envi-
ronmental hazards and the resulting adverse health effects. On the basis of this
analysis, other people in other jobs, some of them very far removed from envi-
ronmental health, can take appropriate action to protect a community's health.
There are numerous examples of how one person, initially working alone or
with a few colleagues, identified a problem, raised the alarm, and persisted in
the necessary investigations and actions to get the problem solved. Joining forces
at an early stage with people in all walks of life helps us to investigate and an-
alyze the problem from all angles and to implement the solution as efficiently as
possible.
This book will show the reader what to look out for and how to approach
problem solving in environmental health. It cannot provide all the specific in-
formation required about each hazard, but it will indicate where to find the ad-
ditional information. By observing, investigating, analyzing, and acting in part-
nership with other professionals and the community, every individual can make
a difference.
The Multidisciplinary Team

Everyone should have some education in environmental health matters, as know-
ing about the environment is a part of living in the world. For any given aspect
of environmental health, there are clearly different levels of expertise required,
for junior assistants on up to the senior professional. All citizens need to know
basic principles of environment and health protection. This knowledge is not just
learned in school, but should be part of lifelong learning. Who should be trained
at the professional level depends on the national needs in environmental health,
present gaps in the workforcc, and resources. Many of the following descriptions
are adapted from Guidelines on Planning Education and Training for the Control of En-
vironmental Health Hazards: A Contribution to Capacity Building at National and Sub-
national Levels. (Pisaniello et al., 1993).
Disciplines are intellectual tools that may be used to solve environmental health
problems; professions are groups of workers, generally defined by discipline, that
exist to advance the status of their discipline. In many developing countries, spe-
cialization may not be realistic, and one person may be responsible for tasks that
call for skills from several disciplines. While the strength and character of the
professions varies from one country to another, it may be helpful, whatever the
setting, to appreciate the range of disciplines relevant to environmental health.
Some examples are presented below, in alphabetical order, as no one discipline
is more important than the other.

Although maintaining competence in one's own discipline is crucial, adopt-
ing a transdisciplinary perspective is also essential. Transdisciplinary thinking goes
beyond the insights that come from different disciplines interacting, it allows new
concepts to emerge that better solve real problems (Rapport, 1995b).
Environmental Health Officer Also termed public health inspectors, or sanitarians,

environmental health officers are generally concerned with public health sur-
veillance and the protection of the environment as it impacts health. Most en-
vironmental health officers are employed at the local government level and con-
tribute to the control of infectious diseases, immunization, and enforcement of
the law with regard to food establishments, food quality and safety, standards of
habitation, and the safe disposal of domestic and industrial wastes. In times of
crisis like floods or earthquakes, immediate action must be taken to prevent the
outbreak of diseases that would inevitably follow the drinking of contaminated
water or the disruption of waste disposal systems. The environmental health of-
ficer's multidisciplinary skills are invaluable in disaster management and pre-
vention. Environmental health officers are in frequent contact with the public.
Indeed, the basic training of these professionals usually involves a considerable
period of salaried work experience, during which time they learn how to inter-
face directly with, and respond to, public needs.
Environmental Health Technician These technicians have essentially the same

tasks as the environmental health officer, but at a lower level of responsibility,
and are supervised by a fully qualified environmental health officer. Specific ti-
tles may be given, e.g., food inspector, building inspector, pest control officer.
Environmental Inspector Environmental inspectors, who often have engineer-

ing or chemistry backgrounds, enforce environmental regulations and provide
advice on following them. Such regulations usually cover atmospheric stack emis-
sions, noise emissions, effluent discharge, wastewater disposal, waste treatment,
and bulk chemical storage and transport.
Epidemiologist Environmental epidemiology can be conceived as the framework

for approaching the task of protecting a population from environmental health
hazards. At the national or provincial level, advanced expertise in environmen-
tal epidemiology is needed to plan and carry out major studies, give expert ad-
vice to government agencies and nongovernment organizations, and teach epi-
demiology in a variety of training schemes. At the local level, many public health
officials need detailed knowledge about how to use epidemiology in their daily
work. Environmental engineering staff, occupational hygiene and safety staff, pri-
mary health care staff, and other people with particular responsibilities (e.g.,
workers' health and safety representatives in industry) need at least a basic un-
derstanding of epidemiological principles. With regard to epidemiological re-
search, it is important to stress that the collection of accurate, unbiased data is
important, but not an end in itself. It is even more important to ask pertinent
research questions and to put the findings into practice. An epidemiologist may be
defined as a health worker who studies the occurrence of disease or other health-
INTRODUCTION 47
related conditions or events in defined populations. Epidemiologists need not he
medically qualified, but they need to be able to creatively link their work with
that of other disciplines, including medicine, biology, and the social sciences. Epi-
demiologists must be able to optimize the use of observational data and routinely
collected information. In practice, the functions of the epidemiologist are broad
and may include health and injury surveillance, collaborative research with clin-
ical medical specialists and heldwork, and the study of health-related behaviors
in the home and at wcrk.
Ergonomist Ergonomics integrates knowledge derived from the human sciences

to match jobs, systems, products, and environments to the physical and mental
abilities and limitations of people. Ergonomics emerged as a discipline during
World War II when the human operator became increasingly the weakest link
in modern sophisticated military systems. After the war, the discipline continued
to grow to meet the challenge of civilian applications. Today, ergonomics en-
compasses a diversity of interests, including cognitive science, human reliability,
occupational physiology, human—computer interaction, and organizational de-
sign and management. Because of the variety of these factors, people from many
different backgrounds may be involved in ergonomic research and practice. These
people, called ergonomists, can be physiologists, psychologists, engineers, phys-
iotherapists, etc. Ergonomists usually work in multidisciplinary teams. For ex-
ample, a physiotherapist and psychologist may work together with engineers to
design a user-friendly instrument display and control panel for an aircraft or a
large container ship.
Health Physicist Health physicists have detailed knowledge and experience in

radiation safety matters. Usually these professionals have studied physics and
have a background or training in the measurement of radiation. Those mainly
concerned with environmental radiochemicals generally have a chemistry back-
ground, whereas nuclear safety engineers usually have a basic qualification in
engineering. Technicians with no formal university qualification may operate in
very narrow aspects of radiation protection in industry. In most countries, the
radiation safety field is often heavily regulated. Consequently, a major function
of these specialists is to oversee compliance with radiation regulations concern-
ing personal and environmental radiation monitoring, inspection and record
keeping, and instrument calibration. Health physicists cooperate with a number
of other health professionals, e.g., physicians and hygienists, in the evaluation
and control of ionizing and nonionizing radiation hazards.
Health Policy Analyst Often government agencies hire individuals specially

trained to advise them about policies that need to be developed or adjusted to
address current problems. These individuals may have backgrounds in econom-
ics, sociology, administration, law, or a variety of other disciplines relevant to
policy making.
Laboratory Analytical Scientist Laboratory analytical scientists includes a broad

group of professionals who deal with the analysis of environmental (food, Wa-

ter, soil, surface, air) and human tissue samples. This group may also include
specialized technicians responsible for lung function testing and monitoring
equipment maintenance and calibration. Scientists in the clinical chemistry lab-
oratory measure chemical changes in the body to determine the diagnosis, ther-
apy, and prognosis of disease. The main work of these technologists consists of
the assay of various chemical constituents in blood, urine, and other fluids or tis-
sues. In the environmental health context, this may mean conducting liver or
renal function tests or enzyme alteration. Microbiology laboratories are chiefly
concerned with issues such as food contamination with mycotoxins and bacte-
ria and water contamination with protozoa. Analytical chemists are responsible
for analysis of environmental samples, e.g., for asbestos, crystalline silica, and/or
biological samples, e.g., for heavy metals and pesticides.
Occupational Hygienist Occupational hygiene (also called industrial hygiene), the

discipline of anticipating, recognizing, evaluating, and controlling health hazards
in the working environment is entrusted with the objectives of protecting work-
ers' health and well-being and safeguarding the general community. In a num-
ber of countries, occupational hygienists deal increasingly with matters of envi-
ronmental health outside the workplace. Although basically trained in
engineering, physics, chemistry, or biology, the occupational hygienist has ac-
quired, usually through postgraduate study and/or experience, a knowledge of
the effects on health of various agents at various levels of exposure. The occupa-
tional hygienist is involved with the monitoring and analytical methods required
to detect the extent of exposure and the engineering and methods used for haz-
ard control. It has been estimated that there are at least 15,000 professional oc-
cupational hygienists worldwide, and although the law in many countries does
not define the function of an occupational hygienist, regulations usually spell out
the needed qualifications and roles of safety engineers, physicians, and nurses.
Occupational Health Nurse Traditionally, the role of the occupational health

nurse has been one of primary care. Because of expanded training and an in-
crease in the number of nurses, however their role has evolved and broadened
considerably. Their various functions include rehabilitation of injured or ill work-
ers, health education and counselling, treatment, environmental control and in-
jury prevention, and health service administration. Of all the occupational and
environmental health professionals, nurses make up the largest group. There are
often various grades within the profession. Increasingly, greater emphasis is be-
ing placed on prevention of disease and injury through environmental control,
although for most nurses, primary health care is still the most time-consuming
activity.
Occupational and Environmental Health Physician Both occupational and envi-

ronmental medicine are largely concerned with preventive medicine and health
maintenance, and both have much in common. Indccd, in an increasing number
of countries, the titles of relevant professional bodies have been changed to formally
unite the two branches of medicine. Occupational physicians carry out health sur-
veillance of workers and diagnosis, management, and investigation of occupational
INTRODUCTION 49
diseases (see Chapter 10). The work also involves health education of workers and
management, the evaluation of occupational hazards, the recommendation of
safety precautions, and statistical analysis of epidemiological data.
Occupational Health and Safety Inspector Traditionally, these inspectors were

recruited from the ranks of tradespersons, e.g., boilermakers, electricians, etc.,
mainly for the purpose of enforcing safety regulations in the construction and
manufacturing industries. While these functions arc still carried out, there is a
worldwide trend toward a more professional inspectorate—i.e., inspectors hav-
ing tertiary educational qualifications, such as an engineering or science degree.
In addition, inspectors in some countries may he expected to undertake personal
exposure measurements or provide advice on exposure control.
Sanitary Engineer Sanitary engineering is a broad area of engineering that includes

water supply, the collection, treatment, and disposal of wastes, air pollution con-
trol, and sanitary inspection of city planning. In a general sense, sanitary engi-
neering is concerned with the adaptation of the environment by engineering means
to the requirements of health. The sanitary engineer has a central role in the so-
lution of environmental health problems related to water and sanitation.
Safety Professional Occupational safety is a multidisciplinary area. Safety profes-

sionals (also termed safety engineers) are drawn from a number of disciplines, e.g.,
engineering and psychology. They may serve as engineers, managers, or consultants,
but they must have a thorough understanding of the causative factors contributing
to accident occurrence and combine this with knowledge of motivation, behavior,
and communication to devise methods and procedures to control hazards.
Statisticians Biostatisticians are concerned with applications of statistics (the sci-

ence and art of collecting, summarizing, and analyzing data that are subject to
random variation), to health issues. They collaborate with epidemiologists, reg-
istry personnel, and other environmental health professionals whose work in-
volves the measurement, research, and analysis of data.
Toxicologist Toxicologists are biological scientists who study the adverse effects
of chemical agents on living organisms. The specialist toxicologist acquires knowl-
edge over many years and is often required to interpret animal experimental data
and other laboratory-generated data for the purpose of predicting adverse hu-
man effects following exposure to toxin(s). Research toxicologists have skills in
animal husbandry and handling, and in in vivo and in vitro testing and experi-
mental design. Regulatory toxicologists advise government authorities on the reg-
ulation of public and occupational exposures. Often toxicologists are involved in
risk assessment in field settings as well.
1. What proportion of people horn in your country in the same year as you
have already died, and what was the major cause of death?

Were any or many of these deaths related to the environment?
What will be the main health problems that you personally may encounter
in the next 30 to 40 years, based on the typical situation for adults in your
country?
Will any of these health problems be related to the environment?
How do human activities and human health relate to sustainable devel-
opment?
What are the differences in health (and disease patterns) between devel-
oped and developing countries? What are the causes of these differences?
What differences are there between men and women in environmental
risk? What is the role of women in sustainable development?
What are the environmental health issues of particular importance to abo-
riginal people in your country?
In your chosen professional role, which will be your most important en-
vironmental health concerns?
In the community where you live, which of the professions listed above
are available as resource people for the community to consult? (make a list based
on interviews, telephone directory, etc.)
INTRODUCTION 51
2
NATURE OF ENVIRONMENTAL
HEALTH HAZARDS
LEARNING OBJECTIVES

• describe the difference between hazard and risk
• explain the logic of the various methods of classifying environmental haz-
ards
• describe a scheme for identifying the level of hazard and toxicity
• explain why knowledge of the toxicology, microbiology, or physical prop-
erties of an environmental hazard is essential to determining the most ap-
propriate approach to its risk assessment (i.e., using a different approach
to carcinogens than to noncarcinogenic acute irritants)
• identify different experimental investigative methods
• explain the biological significance of biotransformation processes
• list the basic characteristics of chemical, physical, biological, mechanical,
and psychosocial hazards
CHAPTER CONTENTS
Hazards and Risks Chemical Classification

Defining Hazard and Risk Routes of Exposure
Types of Environmental Health Distribution, Metabolism, and
Hazards Elimination
Biological Hazards Systemic and Organ-Specific
Types of Biological Hazards Toxicity
Spread of Biological Hazards Reproductive and Developmental
Routes of Exposure Toxicity
Distribution, Growth, and Defense Genotoxicity and Carcinogenicity
Mechanisms of Chemicals
Health Effects Toxicity Testing in Experimental
Investigation Methods Animals
Other Types of Toxicity Testing
Chemical Hazards
InforrilatiOn on Toxicity
Hazard, Risk, and Toxicity
52
Physical Hazards Vulnerable Groups
Types of Physical Hazards Injury Settings
Noise and Vibration Occupational Injuries and
Ionizmg Radiation Ergonomics
Nonionizing Radiation Traffic-Related Injuries
Light and Lasers Home- and Recreation-Related
Pressure Inj uries
Extremes of Temperature Intentional Injury
Concepts in Injury Prevention
Mechanical Hazards
Understanding Mechanical Hazards Psychosocial Hazards
Impact of Injury on the Individual Psychosocial Hazards and Stressors
and Society Health Effects of Stress
HAZARDS AND RISKS
Defining Hazard and Risk

The assessment of health risks posed by specific environmental hazards is fun-
damental to protecting human health and the environment. A hazard is defined
as "a factor or exposure that may adversely affect health" (Last, 1995); it is ba-
sically a source of danger. Hazard is a qualitative term expressing the potential
of an environmental agent to harm the health of certain individuals if the ex-
posure level is high enough and/or if other conditions apply. A risk is defined as
"the probability that an event will occur, e.g., that an individual will become ill
or die within a stated period of time or before a given age; the probability of a
(generally) t]nfavourable outcome" (Last. 1995). It is the quantitative probabil-
ity that a health effect will occur after an individual has been exposed to a spec-
ified amount of a hazard. A hazard results in a risk if there has been exposure-
not if the hazard is contained or if there is no opportunity for exposure.
Types of Environmental Health Hazards

Environmental health hazards arise from both natural and anthropogenic
(human-caused) sources. These include biological hazards (e.g., bacteria, viruses,
parasites, and other pathogenic organisms), chemical hazards (such as toxic met-
als, air pollutants, solvents, and pesticides), and physical hazards (e.g., radiation,
temperature, and noise). Health can also be profoundly affected by tnechanical
hazards (e.g., motor vehicle, sports, home, agriculture, and workplace injury haz-
ards) and psychosocial hazards (e.g., stress, lifestyle disruption, workplace dis-
crimination, effects of social change, marginalization, and unemployment).
On a global scale, environmental factors including overcrcwding, migration,
poor sanitation, and the broad use of pesticides intimately involved in the trans-
mission of infectious agents have had a profound effect on the occurrence of dis-
ease. As discussed in Chapter 1, when infectious diseases are reduced, other en-
vironmental factors causing human diseases (e.g., chemicals, ionizing radiation,
ultraviolet light) become increasingly important as determinants of ill health.
Some traditional hazards, which are still predominant in less developed coun-
tries and rural areas, and modern hazards, which become more important with
increasing urbanization and industrialization, are shown in Table 2.1.
NATURE OF ENVIRONMENTAL HEALTH HAZARDS 53

TABLE 2.1
TRADITIONAL VERSUS MODERN HEALTH HAZARDS
Traditional Hazards Modern Hazards
Disease vectors Tobacco Smoking
Infectious agents Transport hazards
Inadequate housing and shelter Pollution from sewage and industry
Poor-quality drinking water and sanitation Outdoor air pollution from industry and motorcars
Indoor air pollution from cooking Overuse or misuse of chemicals
Dietary deficiencies Industrial machinery
Hazards of child birth Unbalanced diet
Wildlife and domestic animals
Injury hazards in agriculture -
One can study environmental health hazards in various ways. Examining the
nature of the hazard, which can be biological, chemical, physical, mechanical, or
psychosocial, is one approach. Biological hazards can be divided into viruses, bac-
teria, parasites, etc. Route of exposure is also a useful organizing principle, e.g., via
air, water, land. Each route can he further subdivided for purposes of separate
discussion—e.g., indoor versus outdoor air, or groundwater versus surface wa-
ter versus drinking water. Another approach is to focus on the setting where the
hazard occurs, for example, home, work, school, hospitals, or by community.
Table 2.2 provides one conceptual framework of biological, chemical, and phys-
ical hazards by routes of exposure and related factors.
Because environmental health is a huge field, it tends to be taught in frag-
ments. (The nature-of-the-hazard approach is classic in academic settings. Mi-
crobiologists tend to teach the characteristics of biological hazards; toxicologists
discuss the health effects of chemicals; health physicists teach the implications of
radiation on human health; crgononhists discuss biomechanical hazards; and psy-
chologists discuss psychosocial issues. It is, in fact, essential to have some un-
derstanding of the basic microbiological, toxicological, health physics, ergonomic,
and psychosocial sciences in the practice of environmental health. To develop
the public health perspective it may also be useful to focus on routes of expo-
sure. Air pollution, for example, tends to be assessed and managed by a differ-
ent group of public health professionals than water pollution or hazardous waste.
This latter approach lends itself best to advocacy in the community at large. The
middle chapters of this book present the hazards according to their routes of ex-
posure (air, water, food).
The different hazards can also be described in the context of agriculture, set-
tlements, and industry. This approach allows environmental issues to be dealt
with as problems in community and economic development. The later chapters
in the book analyze the health impacts and prevention methods of environmental
issues in relation to settings and development issues (urbanization, energy use,
industrialization, global concerns). This chapter introduces environmental health
concerns according to the nature of the hazards, and outlines the basic issues in
these areas. (The basic physiology needed to understand the effects of environ-
mental hazards on human health can be found in standard physiology texts.)

TABLE 2.2
BIOLOGICAL, CHEMICAL, AND PHYSICAL HAZARDS BY ROUTES OF EXPOSURE
Biological Chemical Physical
AIR
Agent/source Microitrgamsms Fumes, dust, particles Radiation, heat, noise

Vectorial factors Coughing. Contaminated air Climate, unguarded
exhalations exposures
Routes Inhalation, Inhalation, contact Inhalation, direct
contact penetration of
the body
WATER
Agent/source Micrnorganisnis, Discharges, leaching, Radiation; heat in

decayed organic dumping power station
material cooling water
Vectorial factors Insects, rodents, Contaminated lood Accidents, contaminated
snails; animals and water food and water
excrela; food
chain
Routes Bites, ingestion, Ingestion, contact tngestion, contact
contact
LAND
Agent/source Soil organisms Solids, liquids Radiation

Vectorial factors Decaying organic Contaminated food Accidents, contaminated
matter, leading to and groundwater food and groundwater
vector breeding
Routes Contact, bites Ingestion, contact Contact, ingestion
Adapted from Schaefer, 1991 with permission
BIOLOGICAl. HAZARDS
Types of Biological Hazards

Biological hazards include all of the forms of life (as well as the nonliving products
they produce) that can cause adverse health effects. These hazards are plants, in-
sects, rodents, and other animals, fungi, bacterial, viruses, and a wide variety of tox-
ins and allergens. A recently discovered type of biological hazard has been called
prion (disease-producing protein particle), which have been related to a number of
diseases including Creutzfeldl-Jacob ("mad cow") disease (see Chapter 7.)
Environmental health is largely determined by the health effects of exposure
to microorganisms and parasites, whose occurrence and spreading depend on en-
vironmental factors. The biological factors that play a role in the life cycle of the
organisms are discussed below. Hazards associated with larger species will be
treated as an issue of physical safety or as a hazard in transmitting infectious
diseases.
Microorganisms of concern in environmental health include bacteria, viruses, and
protozoa, such as amoebas. Most microorganisms and parasites that cause human
illness need to grow inside the human body to cause it harm. Bacteria and proto-

zoa may live and multiply outside other living cells, and they can survive and mul-
tiply for long periods in food items or water, as long as there are enough nutrients
for them and the pH and temperature are within viability limits. Viruses, however,
cannot multiply outside of other living cells, although some can survive for long
periods and remain infective. To sustain their life cycle, viruses riced to enter ei-
ther human cells or the cells of an animal, insect, or plant. Many diseases caused
by microorganisms are spread directly from one person to another. These diseases,
considered person-to-person environmental health hazards, include tuberculosis
(which is greatly increased by poor housing and crowded conditions) and many
infectious childhood diseases. The five major infectious killers in the world are
acute respiratory infections, diarrhea, tuberculosis, malaria, and measles (Table 2.3).
When a disease can spread from one person to another it is called an infec-
tious or communicable disease. The spread can be direct, by contact between two
TABLE 2.3
ESTIMATED GLOBAL NUMBER OF DEATHS FROM INFECTIOUS AND
PARASITIC_DISEASES, 1993
Disease/Condition Number of Deaths (thousands)
Acute lower respiratory infections under age 5 years 4110
Diarrhea under age 5, including dysentery 3010
Tuberculosis 2709
Malaria 2000
Measles 1160
Hepatitis B 933
AIDS 700
Whooping cough 360
Bacterial meningitis 210
Schistosomiasis 200
Leishmaniasis 197
Congenital syphilis 190
Tetanus 149
Hookworm diseases 90
Amoehiasis 70
Ascariasis (roundworm) 60
Atrican trypanosomiasis (sleeping sickness) 55
American trypanosomiasis (Chagas disease) 45
Onchocerciasis (river blindness) 35
Meningitis 35
Rabies 35
Yellow fever 30
Dengue/dengue hemorrhagic fever 23
Japanese encephalitis 11
Foodhorne trernatodes 10
Cholera 6.8
Poliomyelitis 5.5
Diphtheria 3.9
Leprosy 2.4
Plague 0.5
TOTAL 16,445
Source: WHO, 1995a.

persons, as happens with sexually transmitted diseases, or it can be transmitted by
air, as with the common cold or tuberculosis. One infected person exhales the
microorganism that causes the disease and another person inhales the contami-
nated air. The spread can also take place through vehicles other than air, in ma-
terials that have been contaminated by an infected person, e.g., food contami-
nated with worms (helminths) from another person. Finally, vectors (animals or
insects that carry the microorganism or parasite and infect a person via a bite,
e.g., malaria via mosquitoes) can spread disease as well.
Certain bacteria and parasites produce toxins that can cause disease through
the poisonous action of the toxin, rather than an infection. Much food poison-
ing is this type of bacteria-produced toxic reaction. The difference between in-
fection and a toxic reaction is important. Diseases that are caused by the toxins
that bacteria produce are not contagious. That is, they do not spread from per-
son to person, but are limited to the people who consume the contaminated food.
Thus there is no subsequent risk to other people when the toxin causes the dis-
ease. Nonetheless, the precautionary measures taken to prevent both bacterial
infection and bacterial toxins are similar (clean food preparation and adequate
cooking).
Spread of Biological Hazards
Water polluted by human excreta is the main pathway for the spread of cholera,
typhoid fever, dysentery, other diarrheal diseases, hepatitis, and schistosomiasis.
Inadequate sanitation, the dumping of untreated sewage into surface water, and
poor hygienic practices remain important targets for preventive actions in all
countries. In developed countries with more or less complete sewage and water
treatment, waterborne diarrheal diseases are efficiently prevented, but the cost
of prevention is billions of dollars every year. Overcrowding and poorly venti-
lated housing contribute to the airborne transmission of tuberculosis, measles,
influenza, pneumonia, pertussis, and cerebrospinal meningitis. Unhygienic ani-
mal husbandry helps to transmit zoonoses (animal diseases that can also afflict hu-
mans), e.g., plague and hydatids disease. Contamination of soil and water con-
tributes to the spread of diseases borne by insect and rodent vectors, such as
malaria, trachoma, schistosomiasis, filariasis, yellow fever, plague, typhus, and
trypanosomiasis, while stagnant waters, unsanitary housing, and refuse dumps
are sites that encourage insect reproduction and directly support disease vectors.
This combination enables the spread of the most deadly vector-borne disease,
malaria (Table 2.3).
Many parasites cause tropical diseases, which occur almost exclusively in trop-
ical areas. For most of these diseases, the reason for their geographic confine-
inent is that the disease spread is dependent on an insect vector, which can only
survive in certain climates. Among the more important tropical parasite diseases
are malaria, schistosomiasis, filariasis, and dracunculiasis (Guinea worm disease).
However, many diseases such as tuberculosis are not considered tropical diseases,
even though they are common in the tropics and contribute to the burden of
disease in developing countries.
Environmental changes and disturbances to the balance of natural habitats
may have profound effects on the spread of infectious diseases. New outbreaks

such as the one reported in Congo in 1995 caused by the Ebola virus, have
emerged lately when people encountered them by entering an unfamiliar or re-
mote habitat. Others, such as hantavirus, Rift Valley fever, and cholera, have
reemerged in association with environmental changes (see WRI, 1996 and Chap-
ter 11 for further discussion).
Routes of Exposure
The main environmental exposure routes for biological hazards are air, water,
and food. Some parasites enter the body by penetrating the skin (e.g., hook-
worm, schistosomiasis) and others enter a human body by insect bites (e.g.,
malaria). Bacteria and parasites may also spread from contaminated soil to the
skin or via dust to the air, and eventually infect a person. Person-to-person con-
tact is an important route for the spreading of biological hazards, but this route
is not defined as environmental for purposes of this text.
The spread of microurganisms via air occurs mainly with respiratory diseases,
and is often due to small droplets created while coughing or sneezing. A well-
known example is the common cold. Although not always considered an envi-
ronmental health concern, it could be put in that category, because environ-
mental conditions such as crowding or lack of ventilation in confined spaces
contribute to the spread of the virus via air. Other examples of microorganisms
that spread via air exposure are tuberculosis bacteria and the Legionnaire's dis-
ease bacterium. The latter can grow in poorly maintained air conditioning sys-
tems (in the cooling water) and can spread to a whole building.
The single largest biological environmental health problem is the spread of
fecal bacteria from an infected person to others via water. When the drinking-
water supply for a community is contaminated with feces from one sick person,
a large number of people drinking the water can fall ill and in turn spread the
disease via their feces. Cholera is an example of a serious disease of this type. Very
severe, watery diarrhea is a cardinal symptom of cholera; the person rapidly be-
comes dehydrated and may even die, unless treatment is given to replace the
body liquid lost. A number of other bacteria and viruses in drinking water can
also cause diarrheal diseases and are responsible for the high child mortality rates
in developing countries. The potential for this environmental health hazard to
cause serious disease also exists in developed countries, but the efficient filtra-
tion and disinfecting (chlorination) of drinking water protects these populations.
To sustain protection, it is necessary to maintain systems for water supply and
water purification at a considerable ongoing cost.
In cases of breakdown of water supplies due to natural disasters (such as the
major earthquake in Kobe, Japan in 1995) or wars (such as the disruption of the
water supply to Sarajevo, Bosnia-Herzegovina, in 1992 and 1995), the major con-
cern is the risk of an outbreak of waterhorne disease.
Another exposure route is ingestion of food, which, as mentioned earlier, is
an important medium for growth of bacteria. Low noninfectious levels of bacte-
ria in water can grow into higher infectious levels in food. The number of bac-
teria (or viruses, parasites) required to cause a specific disease in an individual is
called the minimal infectious dose; exposures below this dose will not result in an
infection. The growth of bacteria in the food is dependent on three factors: the

type of foodstuff, the ability of the bacteria to grow in this foodstuff, and, most
importantly, the temperature. Storing many foods at room temperature can lead
to a dangerous buildup of bacteria. At temperatures below 4°C (40°F) or above
60°C (140 0 F), the growth is usually very slow. (Ideally, a refrigerator should keep
the temperature below 4°C at all times.)
The main problem with biological hazards in or on soil is the problem of
helminths (worms) from an infected person that defecates on soil. tntestinal worm
infections are extremely common in poor areas of developing countries, partic-
ularly among children, who play on the soil and are not likely to take precau-
tions. In poor communities where sanitary facilities are inadequate, it may be
necessary (or more acceptable) to defecate outdoors on the ground, and the cy-
cle of worm infecticn is maintained. Worm infections in pets or other animals
can also be the source of this type of exposure. In addition, the reuse of sewage
water for irrigation can cause infection problems among farmers tilling the irri-
gated land, unless special precautions are taken.
Distribution, Growth, and Defense Mechanisms

Many viruses, bacteria, and parasites also cause infections at the place of first
contact with the body—e.g., the common cold virus is inhaled and causes upper
respiratory tract infections, the staphylococcus bacteria may cause boils on the
skin, and intestinal helminths cause worm disease in the intestines after being
swallowed into the gastrointestinal tract. Others infect the body and cause dis-
ease at distant sites. Once a person has been exposed to a biological agent, or
pathogen, this agent will be distributed via blood, lymph, or other body fluids to
the parts of the body most favorable for it to grow. Certain bacteria are very spe-
cific in the sites where they can grow and cause damage—e.g., polio virus can
grow in the intestines and cause diarrhea (this is the way the virus spreads), but
it can also grow specifically in certain nerve cells in the spinal cord and cause
paralysis.
Fortunately, the human body has a powerful defense mechanism against bi-
ological agents, the immune system. This system includes a number of special-
ized cells that identify the infectious agents as intruders that may cause harm
and then engulf theni or attack them with antibodies. Thus, any recognized in-
fection is slowed or stopped by these mechanisms. In many cases the patient re-
covers spontaneously or doesn't develop symptoms at all because the immune
system starts attacking the biological agent as SOOfl as it has entered the body. A
small number of viruses or bacteria would therefore be stopped in their tracks
before infection and disease occur. Thus, until the minimal infectious dose is ex-
ceeded, the disease is not likely to occur. Dangerous diseases that spread rapidly,
such as cholera and measles, often have a very small infective dose. The level of
the minimal infective dose can vary substantially between individuals and is de-
termined by physical condition and nutritional status, among other factors (also
see Chapter 7).
Bacteria and parasites can be slowed down or killed by specific drugs, called
antibiotics. When drugs are not available, the patient may still recover by means
of the immune defenses, but for many diseases, the availability of effective drugs
have made cures much more likely and much laster, e.g., for tuberculosis, strep-

toccccus tonsillitis, and intestinal helminths. For some diseases, such as menin-
gitis, the use of antibiotics is essential to saving the lives of patients.
An important aspect of the growth of bacteria is that some produce power-
ful toxins (chemical substances that cause health damage) when they grow. For
instance, the most dangerous aspect of cholera is the very severe damage to the
lining of the large intestines caused by toxins produced by the cholera bacteria.
This damage produces a large loss of liquid from the body (watery diarrhea),
which threatens the person's life unless intravenous replacement liquid is given.
Similarly, when bacteria grow in food, toxins may be formed that are so pow-
erful that the poisoning is a greater health risk than infection after the contam-
inated food has been eaten. For example, staphylococcus bacteria produce a toxin
that causes diarrhea and vomiting. The most dangerous toxin formed in this way
is that causing the deadly disease, botulism.
Health Effects
When a biological organism establishes itself in the body of a host, such as a per-
son, and causes disease, it is called an infection. Infections may occur in any part
of the body, but many organisms tend to cause infection only in certain organs
and therefore cause distinctive diseases. Each year diarrheal diseases are respon-
sible for a very high fatality rate among infants and children in developing coun-
tries. This is the result of the abundance of exposures to hazards enabling dis-
ease spread, the lack of knowledge at a family level about how to deal with a
sick baby, and the lack of basic health services. In this age-group, a number of
diarrhea-causing organisms can he involved and even common viruses that have
little effects on adults can be fatal. For adults, cholera is the most dangerous dis-
ease, followed by typhoid, paratyphoid, salmonella, and shigella.
Respiratory infections are also very common diseases. Again, babies are par-
ticularly vulnerable. Many adults (particularly elderly people and people with
suppressed immune systems, such as patients with HIV/AIDS) are at risk for tu-
berculosis and pneumonia. The common cold and a variety of influenza-like
viruses have a great impact on our daily lives (e.g., days off work), but gener-
ally patients recover in a few days.
Sexually transmitted diseases have taken on a whole new importance because
of the spread of HIV/AIDS. Although AIDS itself is not considered an environ-
mental disease, it may well influence the occurrence of other environment-
related infections. Because of the damage AIDS does to the immune system and
the body's defense against other infections, AIDS has lead to a major resurgence
of tuberculosis. Resistance to antibiotics has developed among many bacteria and
parasites. Infections caused by the resistant organisms may be difficult to treat
and may spread to others who would not be exposed if treatment were success-
ful. Some cases of tuberculosis, for example, have been caused by inefficient treat-
ment of patients with antibiotic-resistant tubercle bacilli who then infect others.
Investigation Methods
Microbiologists have developed laboratory methods to identify and quantify the
occurrence of most viruses, bacteria, and parasites in any medium. These tools
are constantly being refined on the basis of new knowledge about the mi-

crostructure of biological agents, particularly the structure of their DNA. In this
way, samples of feces from a person with diarrhea can be tested to identify the
specific agent responsible for the disease. 11 it is likely that the agent also occurs
in blood, further analysis of blood can he carried out. Parasites can also be iden-
tified in blood. Some of them, like the malaria plasmodium, are easily detected
using a microscope. The existence of antibodies against specific microbes can also
show whether the person has had an infection in the past. To quantify the con-
centration of viruses in a material, samples are taken and inserted into living cells
where the viruses grow and are eventually quantified. For bacteria, the growth
before quantification can be generated in special growth media, such as cigar plates.
For larger parasites, direct counting of organisms under a microscope may
suffice.
Normally the clinical health staff carry out these investigations on materials
from patients. In environmental health investigations measurements of mi-
croorganisms are often taken from environmental materials, such as drinking wa-
ter, foods, or soil. The same type of tools used for identifying and quantifying
the occurrence of biological agents are used on these materials. One important
difference in approach is the use of surrogate indicators of the biological agents
of concern. For instance, for routine monitoring of drinking water, measurements
of the Escherichia coil coliforni organism's bacteria are taken to assess whether the
water has acceptable quality or not. These bacteria do not normally cause dis-
ease, as they are the most common bacteria in the normal intestinal bacterial
flora. The reason they are used as indicators of water quality is that they show
whether the water has been contaminated by feces, which is the most important
source of disease-causing bacteria in drinking water.
CHEMICAL HAZARDS
Hazard, Risk, and Toxicity

Approximately 10 million chemical compounds have been synthesized in labo-
ratories since the beginning of the present century. About 1 % of these chemi-
cals are produced commercially and used directly (e.g., as pesticides and fertiliz-
ers); most chemicals are intermediates in the manufacture of end products for
human use. There is virtually no sector of human activity that does not use chem-
ical products, and these products have indeed created many benefits for society,
such as the treatment of disease with pharmaceutical products and the use of
fertilizers to increase food production.
All chemicals are toxic to some degree, with health risk being primarily a
function of the severity of the toxicity and the extent of exposure. However, most
chemicals have not been adequately tested to determine their toxicity.
Some international efforts have been made to rectify this situation. Specif-
ically, in 1976 the United Nations Environment Program (UNEP) established
the International Reqistry of Potentially Toxic Chemicals (IRPTC) (see website:
irptc.unep.chlirptcldatahank.html), which now has a computerized central data
file containing data profiles for hundreds of chemicals. Special files are available
on waste management and disposal, chemicals currently being tested for toxic

effects, and national regulations covering thousands of substances. In 1980, the
WHO, UNEP, and International Labor Organization (ILO) set up the International
Program on Chemical Safety (IPCS) to assess the risks that specific chemicals pose
to human health and the environment. The IPCS publishes its evaluations in five
forms: the detailed Environmental Health Criteria, which are intended for scientific
experts; a short, nontechnical Health and Safety Guide for administrators, man-
agers, and decision makers; the International 6'hemical Safety Cards, which are for
ready reference in the workplace; the Poisons Information Monographs for medical
use; and the Concise International Chenucal Assessment Documents. (see www.who.
intlpcs; for the Environmental Health Criteria, you may go directly to www.
who.int/pcs/pubs/pub_list.htrn)
It is important to distinguish hazard and risk from the term toxicity. The tox-
icity of a substance is defined as its inherent capacity to cause injury to a living
organism (i.e., a person, animal, or plant). A highly toxic substance will damage
an organism even if only very small amounts are present in the body. A sub-
stance of low toxicity will not produce an effect unless the concentration in the
target tissue is sufficiently high. For the chemical to pose a risk there must be a
real or potential exposure to it. A toxic chemical that is used in a totally enclosed
process may in itself possess the capacity to induce adverse health effects, but
may not pose a real health risk, since there is virtually no possibility of expo-
sure. Factors that might be considered when assessing the risk posed by a toxic
substance include the quantity of the substance actually absorbed (i.e., the dose),
how the body metabolizes the substance, and the nature and extent of the in-
duced health effect at a given level of exposure (dose—response or dose—effect re-
lationship; see Chapter 3). The dose, in turn, depends on the route of exposure
and the length, duration, and frequency of exposure. One must also consider in-
dividuals in the population who might he more sensitive to the toxin and whether
the injury is permanent or reversible. Thus to identify and categorize chemical
hazards, knowledge is needed of the following: (1) their physical and chemical
properties; (2) their routes of entry; (3) their distribution and metabolism; and
(4) the effects they have on body systems. Finally, it is necessary to know (5)
how to identify chemical hazards in real settings (see Chapter 3).
Chemical Classification
There are numerous chemical classification systems available. For those without
a basic chemistry background it is useful to be aware of the classification of chem-
icals into two major classes: (I) inorganic chemicals (which contain none or very
few carbon atoms), and (2) organic chemicals (which have a structure based on
carbon atoms). (The reader interested in the specific chemical structure of dif-
ferent compounds is referred to standard handbooks in chemistry or the IPCS
Environmental Health Criteria).
Inorganic Substances Halogens are elements that form a salt by direct union with
a metal. They include fluorine, chlorine, bromine, and iodine. At standard tem-
perature and pressure, fluorine and chlorine are gases, bromine is a liquid, and
iodine is a solid. When placed in water, reactions occur, yielding acids that irri-
tate tissues. As individual elements and compounds, the halogens have their own

inherent toxicity. The primary symptom of the inhalation of halogens (exclud-
ing organohalogens) is respiratory tract irritation, with the severity depending on
concentration. Chlorinated and fluorinated hydrocarbons, which are formed dur-
ing the reaction of halogens with organic compounds, will he further discussed
in Chapter 11, where the impact of halogenated hydrocarbons on the depletion
of the ozone layer and the implications for the global environment are addressed.
Corrosive materials include alkaline compounds such as ammonia, calcium hy-
droxide, calcium oxide, potassium hydroxide, sodium carbonate, and sodium hy-
droxide, among others. These cause corrosive local irritation of tissues such as
the skin, eyes, and respiratory tract. These effects can also be caused by acids.
Sulfuric acid and chromic acid are common industrial chemicals. Other com-
pounds with ccrrosive or irritation effects include the common air pollutants
ozone and nitrogen oxides. Ozone (0) is very irritating to all mucous mem-
branes (e.g., eyes, nose, and mouth) whereas nitrogen dioxide is a moderate ir-
ritant. Both can trigger asthma attacks.
Metals such as cadmium, chromium, copper, lead, manganese, mercury, nickel,
and arsenic are toxic and environmentally persistent. Of these, chromium, cop-
per, and manganese are essential metals in that they are required by living or-
ganisms. Both the environmental fate and the level of toxicity of metals depend
strongly on their physical and chemical form. Living organisms are capable of
changing the chemical form and thereby altering health risks related to exposure
to these chemicals. For example, bacteria can convert mercury ions to methyl
mercury, which is fat soluble and may therefore accumulate in fish and enter
the human food chain. Similarly, some forms of organic lead (methyl and ethyl
derivatives such as tetraethyl lead) are soluble in organic solvents and are used
as anti-knock agents in gasoline. Because lead compounds are neurotoxic, their
use is being phased out in many countries. For most of these chemicals, IPCS
Environmental Health Criteria have been developed.
Organic Compounds Hydrocarbons are basically a string of carbon molecules with

hydrogen attached to the carbon molecules. Aliphatic hydrocarbons, either short-
chain or paraffin (tong-chain), come almost exclusively from petroleum and can
be saturated, implying that no further atoms (especially hydrogen atoms) can be
added to the molecule. These hydrocarbons include (from the smallest to the
largest molecules) methane, ethane, propane, butane, pentane, hexane, hcptane,
and octane, among others. Methane and ethane are gases and are relatively in-
ert biologically, while hydrocarbons bigger than ethane (i.e., propane, butane
etc.) are central nervous system depressants asphyxiants and flammable. Mucous
membrane irritation increases from pentane to octane. Olefins, or saturated
aliphatic hydrocarbons, are molecules having one or more double bonds between
molecules that potentially could be broken so that hydrogen atoms could be added
to the molecule. They are thus not saturated with hydrogen atoms. These hy-
drocarbons are also formed as by-products of petroleum breakdown. Specific un-
saturated aliphatic hydrocarbons include ethylene, propylene, 1,3 butadiene, and
isoprene.
Saturated and unsaturated hydrocarbons may also exist in an alicyclic (i.e., cir-
cular) form, e.g., cyclohexanc, methylcyclohexane, and turpentine. Here, the hy-

BOX 2.1
Xenoestrogens
Estrogens form a class of steroid hormones synthesized both in males and females.
These hormcnes play an important role in human reproduction, including sexual dif-
ferentiation, development of female secondary sex characteristics, and development
and functioning of the testes. Hormones exert their action by binding to a specific re-
ceptor. When a hormone hinds to a cellular receptor to form a hormone-receptor
complex, a number of reactions take place that eventually result in a physiological ef-
fect. To develop and function normally, hormonal blood levels have to be regulated
very accurately. This regulation of hormone levels is determined by the rate of syn-
thesis and elimination by metabolism. This mechanism of regulation can be disturbed,
however, when humans or other organisms are exposed to environmental chemicals
that are also capable of binding to the estrogen receptor. In principle, there are two
possible reactions. (I) The binding of the environmental compound to the estrogen
receptor results in the same cellular response; this is called an estrogen-mimicking effect.
(2) Binding to the receptor does not result in the normal response. This may indicate
that the xenoestrogen, not normally present in the body, has (permanently) blocked
the receptor, making it unable to interact with endogenous estrogens.
Humans may be exposed to xenoestrogens in many different ways. The human
diet may contain large amounts of phytoestrogens such as lignans and isoflavones.
Estrogen-blocking effects have been demonstrated in women who ate a iscflavones-
enriched diet. However, most phytoestrogens are metabolized and excreted in urine
in the same way as endogenous estrogens and therefore do not accumulate in the
body. The opposite holds true, however, for some other xenoestrogens, including poly-
chlorinated biphenyl (PCB5), dioxins, and furans. Exposure to some PCB congeners
has been correlated with reduced sperm motility and density. Furthermore, after in
utero exposure, increased fetal loss, reduced birth weight, and behavioral and devel-
opmental effects were reported after severe poisoning accidents in Japan and Taiwan,
Occupational exposures to estrogenic compounds (like Kepone) have also resulted in
decreased sperm count and motility, and abnormal sperm morphology.
Other xenoestrogens to which humans can be exposed are alkylphenols,
phthalate esters, and bisphenol-A. Considerable concern about these compounds has
HO
Estrogen (Estradiol) Testosterone
cl
ci_ O__O_ c
CI-C-C)
OH_O-C = C_O_OH
OH 2 OH2
ci OH 3 OH3
DDT Diethyistilbestrol
Figure 2.1 Chemical structure of estradiol, testosterone, diethylstilbestrol, and DDT.

From Colburn et al., 1996, with permission. (anitinued

,lfifll(,'I)
been raised because they are So pervasive in the environment. In particular, intake
of phthalates, which may amount to several hundreds of ig/kgIday, mainly by con-
sumption of food, may result in estrogenic elfects. The most obvious exposure to
xenoestrogens is, of course, the direct administration of synthetic hormones, such
as diethylstilbestrol (DES), the effects of which are well documented in the offspring
of women who took it. In some countries, the same hormones may be preseru in
incat and dairy products. The similarities in chemical structure between endogenous
estradiol and the xenoestrogens DES and dichlorodiphenyl-trichloroethane (DDT),
are shown in Figure 2.1
Whether xenoestrogens in the environment are having an effect on people in
general is unknown and certainly unproven. The data on falling sperm counts among
men are not consistent from one place to the next and there is little evidence of a
rise in breast cancer rates among women when age and birth history is taken into
account. The risks associated with environmental xenoestrogens are better docu-
mented for animals than for people. For example, it is not clear that exposure to
xenoestrogens, which tend to he weakly estrogenic in environmental exposure, can
match the direct exposure to estrogen that women have today from living longer
and healthier.
drocarhon chain bends around so that the last carbon molecule is attached to the
first to form a circle. In general, the longer the carbon chain (whether saturated,
unsaturated, or cyclic), the more lipid (fat) soluble. Unsaturated hydrocarbons
are more reactive and usually more toxic than saturated ones. The aromatic hy-
drocarbons are also circular molecules containing one or more benzene rings. A
benzene ring is a circular six-carbon hydrocarbon with alternating single and dou-
ble bonds.
For various reasons, a berizene ring is a very stable structure (i.e., a lot of en-
ergy is needed to break a benzene ring). This category of chemicals is further
classified depending on the number of benzene rings and the type of linkage be-
tween them in the molecule. These groups are (1) benzene and its aliphatic and
alicyclic derivatives; (2) polyphenyls, i.e., two or more noncondensed rings; and
(3) polycyclic ring.c, or two or more condensed rings. Examples of aromatic com-
pounds include benzcnc, toluene, styrene, and naphthalene. Aromatic hydrocar-
bons act as primary irritants to the mucous membranes and cause central ner-
vous system depression. In addition, some have particularly toxic and carcinogenic
properties. For example, benzene has long been known for its toxicity to the
hematopoietic (i.e., blood) system and its ability to cause leukemia. In general,
the more benzene rings in the molecule, the less soluble and more persistent it
is in the environment (i.e., it doesn't break down easily). Because of these last
two features, these chemicals are more likely to be carcinogenic or ecotoxic, al-
though other characteristics of the molecule (such as its three-dimensional shape)
may also contribute to its toxicity.
Certain types of organic compounds have estrogen-like activity (see Box 2.1).
Such action by exogenous chemicals is believed to occur because of the spatial
(geometric) resemblance between the toxicant and the natural (endogenous) es-
trogen hormone. Links to breast cancer and male infertility have been hypoth-
esized for these estrogen-like substances (Davies et al., 1995; Sharpe and Skakke-

back, 1993). Similar concerns about specific disease causation have been raised
for chemicals that disrupt the endocrine system (endocrine disruptors), thought by
some to be the heralding of a new wave of environmental concern (Colborn et
al., 1996).
Halogenated hydrocarbons (i.e., hydrocarbons with at least one atom from the
halogen group of atoms [fluorine, chlorine, bromine or iodine] attached) are
among the most commonly encountered industrial chemicals. Examples include
chloromethane, dichioromethane, chloroform, and carbon tetrachloride. Chem-
icals in this group are extensively used for dry cleaning or as industrial solvents
(e.g., trichloroethylene) and in the production of plastics (e.g., polyvinyl chlo-
ride [PVC]). In general, the larger and more chlorinated the compounds are, the
more the compounds cannot be broken down, and therefore they remain in the
environment. Chlorinated cyclic hydrocarbons are environmentally damaging be-
cause they persist for long periods and are consumed and accumulated by wildlife.
Besides being persistent in the environment, the bioaccumulation of these com-
pounds and their excretion in human and animal milk pose high risk to infants.
(Bioaccumulation will be discussed in Chapter 7. Persistent organic pollutants are
discussed further in Box 2.2.) Toxic signs of human exposures are central ner -
vous system alterations, developmental delay in children, immune system sup-
pression, and a persistent skin rash called chloracne. Some environmental poly-
chlorinated hydrocarbons such as dioxins originating from waste incinerators are
frequently discussed in relation to their carcinogenic potential. A model com-
pound, 2,3,7,8-tetrachlorodibenzo-para-dioxin, is known to be carcinogenic to
humans (IARC classification group 1). However, other polychlorinated dibenzo-
para-dioxins are not classifiable as carcinogenic to humans (group 3).
Alcohols are hydrocarbons in which at least one or more hydrogen atoms are
substituted by a hydroxyl (molecule composed of an oxygen and a hydrogen
atom) group. Specific alcohols include methanol, ethanol, and propanol, which
are toxic to several organs, most notably to the central nervous system. For ex-
ample, fetal alcohol syndrome is a recognized disorder in which ethanol inges-
tion by the mother damages the child before birth. The chronic effects of methanol
ingestion include blurred vision and ultimately blindness; this situation is most
common when alcohol is drunk from illegal and contaminated liquor distillation.
Higher-molecular-mass (i.e., bigger) alcohols can produce a dermatitis (i.e., a skin
rash).
Glycols and derivatives, such as ethylene glycol, have two hydrogen atoms sub-
stituted by hydroxyl groups. They are used as anti-freezing agents and in hu-
mans to produce anesthetic and dermal effects. Other types include ethers, which
contain carbon-oxygen-carbon linkages; epoxy compounds, which are cyclic
ethers; ketones, aldehydes, and organic acids; anhydrides, esters, and organic
phosphates; cyanides and nitrites; nitrogen compounds; and miscellaneous or-
ganic nitrogen compounds. Toxicological information is available about all these
classifications of chemicals through the IPCS Environmental Health Criteria. (see
www.wiio.int/pcs/pubs/pub—list.htm)
Organic solvents are widely used in industry and pose a potential risk of high
exposure to workers. Many of these chemicals are toxic, persist in the environ-
ment, and are known or suspected to be carcinogenic (e.g., benzene, trichloroeth-

BOX 2.2
Persistent Organic Pollutants
Persistent organic pollutants (POPS) constitute an important group of chemicals of

environmental concern. They are branched-chain or ringed organic compounds, are
often highly chlorinated, and are resistant to biological, chemical, and photolytic
breakdown. Consequently, POPs remain in the environment for many years. They
are fat (lipid) soluble, accumulate along food chains, and are often toxic to living
organisms. Health effects may involve disturbances of the nervous or immune sys-
tem, or increases in the risk of certain cancers. The POPs include the first genera-
tion of organochlorine pesticides (e.g., chiordane, DDT, heptachior, minex, and
toxaphene); polycyclic aromatic hydrocarbons such as pyrenes and anthracenes,
which are generated in the combustion of coal or other (fossil) fuels; dioxins and
furans, which are by-products of certain chemical processes (e.g., in the puip and
paper industry) or waste incineration; and PCBs, which were produced on a large
scale for use as dielectric and hydraulic fluids, among other applications. Some of
the POPs mentioned constitute large chemical families of related compounds called
congeners; for example, there are 209 PCBs and 670 or more toxaphenes (see Chap-
ter 11).
Contributed [i, Evert Nieboer, McMaster University, Canada.
ylene). Some of these compounds, such as benzene and toluene, are also pres-
ent in combustion products of organic material, such as when tires are burned.
Paints used to include organic or inorganic hydrobarbon solvents, but increas-
ingly, water is being used as a solvent, which has significantly reduced the health
risks of painters.
Routes of Exposure
Chemicals can be released into the environment in many different ways. These
include the naturally occurring chemicals released during natural geological
processes and from mining and dredging, as well as wastes from many indus-
trial, agricultural, coirimcrcial, domestic, and manufacturing sources. Chemical
pollution may also occur by the unintentional release of chemicals during pro-
duction, storage, and transportation of products such as household products. Air,
soil, fresh waters, and oceans are all subject to chemical pollution. Contamina-
tion of food involves absorption of chemical residues in the food chain as well
as the use of chemicals in food processing. Natural toxins (aflaloxins, ochratox-
ins, pyrrolizidne alkaloids) also cause a variety of illnesses.
Exposure to chemical hazards may occur via all types of exposure: inhalation,
oral ingestion, absorption through the skin, absorption through the eyes, pla-
cental transfer from a pregnant woman to the fetus, inoculation and direct pen-
etration to target organs, and from mother to child lhrough breastfeeding. In the
nonoccupational environment, ingestion of substances containing chemicals is
NATURE OF ENVIRONMENTAL I-IEALTI-I HAZARDS 67

the most Common route of exposure. In the workplace, because of the nature of
exposure, duration of the workday, and character of the compounds, inhalation
is the most significant route of entry, followed by skin absorption and ingestion.
Distribution, Metabolism, and Elimination
Once a chemical has entered the body, it may be metabolized, excreted, or ac -
cumulated. Figure 2.2 shows the routes of absorption, distribution, and excre-
tion of potentially toxic substances. Usually, absorption is most rapid from the
lungs, less rapid from the gastrointestinal tract, and least rapid through the skin.
Different chemicals follow different pathways. In the case of metal exposures, all
pathways may be of relevance. The materials potentially useful for biological
monitoring are marked in Figure 2.2 with dotted lines.
After inhalation of particulate matter, the size of particles determines where
in the respiratory tract they are deposited and therefore also where they exert
their toxic effect. Gases have effects in the respiratory tract depending on their
solubility in water. Gases that do not dissolve easily in water can reach the alve-
oil relatively easily, and may therefore cause health effects throughout the res-
piratory system. Exposure to particulate matter is common in industrial settings,
resulting in well-defined diseases, for example, silicosis (lung restriction and ob-
struction) due to inhalation of crystalline silica; asbestosis (lung inflammation!
Exposure
Media I Air, water,
dirt, etc. Air
Food, water,
I drugs
inhalation 4 1 exhalation J ingestion
Major uptake Respiratory 'I

pathways j, Skin
tract J (
GI-tract
exfoliation
Transport and
Distribution f
I' 1 ( organs
Other i Blood T~ Liver
Kidney
Maj or
'S - _,
I
excretory ( Sweat ' Hair '
I
'I Urine ' i Feces'
I
pathways - - - - - - ' S -
external contamination
Figure 2.2 Routes of absorption, distribution, and excretion of potentially toxic substances.
Dotted lines indicate materials potentially useful for biological monitoring. Modified from
Clarkson et al., 1988, with permission.

fibrosis) as a consequence of the inhalation of asbestos fibers; and lung cancer
due to exposure to asbestos, nickel oxides, and sulfides, chromium compounds
(chromates), and arsenic trioxide. For the development of these chronic diseases,
high levels of exposure of long duration are usually required (typically 10-20
years). Furthermore, particulate air pollution of diameters less than or equal to
2.5 im (the PM25 fraction) appears to be linked to increased mortality from lung
cancer, cardiopulmonary disease, and other respiratory causes. These effects have
been quite strongly correlated with suspended sulfates and contributions from
metals are also suspected (see Chapter 5).
Once chemicals are absorbed from the lungs, the skin, or the rectum (sup-
positories), they may enter the general blood circulation directly and be rapidly
spread through the body in an unmodified form. Chemicals absorbed from the
stomach and intestines (the gastrointestinal [GI] tract) enter the blood and are
transported by the hepatic portal system to the liver where they may be modi-
fied by a series of reactions. This modification process in the liver and, to a lesser
extent, in other organs is referred to as biotransformation. These reactions have
also been referred to as detoxification, when the transformation causes reduced
toxicity, or bioactivation, when it causes increased toxicity.
Biotransformation can be divided into two distinct phases: phase I and phase
II. In general, the biotransformation process converts hydrophobic (water-
hating) or Iipcphilic (fat-loving) compounds into niore hydrophilic (water-loving
and therefore water-soluble) ones. During phase I, the molecule is altered by the
introduction of electrostatically charged (polar) groups (e.g., —OH, —COOH, and
—NH2) (Fig. 2.3). The phase 1 reactions may also lead to the unmasking of such
groups in the original compound. These changes may take place as a result of
oxidation, reduction, or hydrolysis. In phase II, substances are combined with
hydrophilic endogenous compounds. The result is a substance with a sufficiently
hydrophilic character to allow rapid excretion. These so-called conjugation reac-
tions can occur with a variety of substances—usually intermediates in metabo-
lism, such as glucuronic acid, sulfate, glycine, and glutathione. Sometimes the
process of biotransformation, especially phase I, results in a more active chemi-
cal compound that may react with DNA or other important structures in the cell.
Some very important carcinogenic chemicals, such as benzene, require phase I
transformation to become reactive. Because some of these exist for only a very
short time, just long enough to induce damage, they are usually difficult to de-
tect or measure (Box 2.3).
Chemicals that undergo phase I and phase ti reactions are normally those that
are fat-soluble (lipophilic) and tend to accumulate in body fat and milk if not
converted to an excretable form (Fig. 2.4). If this fat is mobilized under stress
conditions, the substances may return to the blood and cause acute intoxication.
Some of these substances may be broken down to components by bacteria in the
gut, from where they are then reabsorbed to undergo phase II reactions. Water-
soluble substances (and dissociated polar, electrostatically charged, substances)
go directly to the blood circulation, from which they may be lost in expired air
from the lungs (if they vaporize readily), to the kidneys and urine (following ul-
trafiltration), and/or he actively secreted in other secreted fluids such as tears,
saliva, milk, or sweat,

BOX 2.3
Bioactivation of Benzene
Many carcinogenic chemicals require hioactivation for their action. For instance,
during metabolism of aflatoxins, vinyl chloride, benzo al pyrene, and benzene, highly
reactive intermediates, epoxidi's, are formed. These epoxides exist for only a very
short period of time because of their high instability and reactivity. Since the epox-
ides are electrophilic, they react with nucleophilic groups, including those in bio-
macromolecules like proteins and DNA. As a result of this reaction, cellular processes
can be disturbed and the generic code may be modified. As will be discussed later,
changes in the genetic code may eventually result in tumor formation and cancer.
The chemical formation of the epoxide from henzene is illustrated, in Figure 2.3.
After the formation of phenol, this end product of the phase I reaction is conju-
gated (coupled) with glucuronic acid, an endogenous compound, to form phenyl-
glucuronide during phase II. To show the structtiral resemblance between different
types of chemicals that are converted to reactive epoxide intermediates during phase
I reactions, the structures of vinyl chloride as well as its epoxide are also shown in
Figure 2.3.
Phase I Phase U
—(O
—>
mono-oxygenase
0 U <0 — OH . Gluc
Benzene Benzene epoxide Phenol Phenyiglucuronide

(the original chemical) (a dangerously toxic (an intermediate that (hydrophilic:
product) the body can handle) easily excreted)
H H mono-oxygenase H 0 H
/ ___ ___
c=c c—c etc.
/ \ /
H Cl H Cl
Vinylchioride Vinyl chloride epoxide

(the original chemical) (a dangerously toxic product)
Figure 2.3 Formation of epoxides during the metabolism of henzene (A) and vinyl
chloride (B). Modified from Niesink et al., 1996, with permission.
Systemic and Organ-Specific Toxicity

Toxicity was defined previously as any harmful effect of a chemical or a drug
on a target organ. Systemic toxicity can be expressed as an effect on the body sys-
tem after a chemical has been absorbed and spread by the blood throughout the
body, as opposed to simply a local reaction, which affects only the organ where the
chemical first made contact with the body. Some toxicants exert their effects on
specific organs, such as the liver, kidney, or nervous system (see Box 2.4). They

I xenobiotics I
I I I I
highly lipophilic lipophilic polar hydrophilic
metabolically stable i i I
accumulation in body fat
phase I
(bioactivation or inactivation)
oxidation, reduction, hydrolysis
lar
phase II
(bioinactivation) conjugation
hydrophilic
extracellular mobilization
Figure 2.4 Metabolism and ex- plasma circulation

cretion of potentially toxic sub -
stances. Adapted from Niesink
billary excretion renal excretion secretions
ci al., 1996, with permission.
may also create allergic diseases through altering the immunologic system, or they
may alter the DNA to cause cancer or birth defects. Whether the toxic effects are
systemic or local, they can he acute or chronic, and temporary or permanent.
Rep rodi ictii 'e a) id Dei 'c/op/flea tal Toxicity

Various toxic chemicals have effects on both male and female reproductive sys-
tems. Exposures of concern may occur before or alter conception. They may at-
feet fertility, sexual function, and libido, but of particular concern are the po-
tential effects on the fetus, which may include genetic abnormalities, interference
with normal development, and poisoning of the fetus before birth. The results of
those processes may include congenital defects, failure to thrive and develop nor-
mally, low birth weight, and miscarriages (spontaneous abortions). The nature
of the outcome depends on the type and extent of exposure as well as the tim-
ing of exposure with respect to fetal development. Figure 2.5 shows the critical
periods of fetal development by organ system. 11 is important to realize that birth
defects and all the other negative outcomes may happen even without exposure
to toxic chemicals; often the only clue to the presence of a reproductive risk is
that the frequency of such adverse birth outcomes is increased. The extent to
which toxic chemicals contribute to our present level of reproduction-related
health problems is completely unknown, but the frequency of birth defects over-
all does not seem to he rising.
Genotoxicity ill/il Ca rcinoqen icity of Clieni icaLc

Chemical, physical, and biological agents can interact with DNA, resulting in
structural and/or functional changes that might lead to the alteration of genetic

BOX 2.4
Major Patterns of Health Effects that May Be Caused
by Toxic Substances
• Svstenuc toxicity. Toxic effects that result front absorption of a chemical and its
spread to different body syslenis. Examples of common systemic toxicity include
the serious, sometimes fatal, poisoning that may occur from contact with certain
organophosphate pesticides parathion and inhalation of organic solvents.
Orqcin-specijic toxicity. Certain chemicals have a target organ specificity (i.e., they
harm a certain organ rather tliamì others) often because of biotratisforniation or
bioconcentration. The route of exposure niight also be responsible for specific or-
gan injury.
Liter toxicity. Most chemicals are metabolized in the liver. Therefore, the liver be-
comes the target organ for many chemicals. Organic solvents (CC I. chloroforni, I
ethanol) and certain trace metals (copper, cadnuum) may cause extensive liver
damage, characterized by fatty changes, necrosis, fibrosis, and alteration of the
structure.
Kidney toxicity. Many xenobiotics are removed by glomertilar filtration and tubu-
lar excretion, while essential elements are reabsorbed in the tubuli. Chemicals
with kidney toxicity include metals (e.g., mercury, cadmium, lead).
Skin toxicity. Skin rashes are a coinnion reactioti to chemicals. Allergic reactions
can occur in sensitive individuals whereas skiii irritatioil can occur in anyone ex-
posed to a wide variety of irritatilig chemicals. Certain chieitticals produce a char-
acteristic type of skiii reaction, which provides a clue as to the exposure the pt'r-
son may have experienced. Most, however, do not.
Neiin, toxicitv. Most toxic substances act on the central or peripheral nervous sys-
tem. Futictional or organic alterations of iietirotransmitters can cause excitative I
symptoms or paralysis (through exposure to organophosphates, chloritiated or-
ganic compounds. metals).
7 Inimunotoxicity. The function of the iitiiituiie system ensures (1) nonspecific de-
tense mnechaiiisins against agents for which no previous sensitization has oc-
curred, and (2) specific, adaptive mechanisms directed against specific agents to
winch the organism has previously been sensitized or with which it has been iii-
fected. The body has very complicated mechanisms to defend itself against attack
by viruses and bacteria and these can be inipaired by exposure to certain chem-
icals. One result of such exposure may be a subtle increase in the frequency of
viral illnesses, such as influenza or colds. Impaired immunological reactions can
lead to allergy. Molecules can react with other body components, altering their
properties and hence their biological functions. This may result in the immune
system treatitig these components as foreign. Antibodies may be produced that
bind to abnormally altered body components and trigger inflamniatioti, tissue
breakdown, and other harniful effects.
codes and information. This complex process involves gene mutation, chromo-
somal alteration (structural and numerical), and/or gene rearrangements, all oh
which are described briefly in Box 2.5.
Cancer arises as a consequence of multiple genetic and noilgenetic events that

Gestational age (in weeks)
1 2 3 4 5 6 7 8 9 1/ 16 II 20-36 38 (term)
Organ Division - Embryonic Period -. -.0--- Fetal Period 10
System and
Implantation
IlIuIIuIIIuIIIIIIuII
Brain
Heart - uIuuuuuuuu,IuIIuuIIII
(Usually not
Limbs susceptible IuuIuuIuuIuIIIIIuuuIuII
to teratogens)
Eyes uIIuu'uI.IIIIuIIu.uuu.,IIuIII
Ear uuIuIuuIIu'IuIIIuIuIuIu,IIIIuuIuIIuIlI
Teeth IJuIIuJu.uuuI,uIuuI
Palate uIuIIuuuIIuIuIIIuIuuII,-
External
Genitalia II I I II I II I I I I I I I I
Prenatal
death Major Morphological Abnormalities Physiological
Defects and
Minor Morphological
Anomalies
ui.. highly sensitive period - continued development, but less sensitivity to teratogens
Figure 2.5 Critical periods of fetal development by organ system. From Jedrychowski and
Krzyzanowski, 1995, with permission.
might lead to uncontrolled proliferation of cells. Although the individual steps

are difficult to distinguish, there are two major classes of carcinogenic agents:
agents primarily reacting with the DNA, and agents that have primarily non-
genetic reactivity, acting through nongenetic mechaiiisrns. In reality, carcino-
genesis is a complex process, involving several stages in which genotoxic and
nongenotoxic mechanisms take place. The multistage process of carcinogenesis
can be characterized by three major steps: (1) initiation, which leads to (2) pro-
motion, which develops into (3) progression.
Initiation Mutagenic chemicals, ionizing radiation, and viruses may cause

changes in the DNA, creating an initiated cell. The initiated genotype is regarded
as a potentially malignant state, which may be converted to a cell with the ca-
pacity for unrestricted proliferation. Initiation is thought to be dose related, which
means that an increasing dose leads to greater numbers of initiated cells or cells
with multiple crucial mutations. It occurs only in a small proportion of the tar-
get cell population and with greater frequency if the cells in the tissue are rapidly
dividing. This can be explained by the fact that the DNA in the dividing cell is
less protected and therefore more susceptible to chemical alterations. Further-
more, rapidly dividing cells have less time to repair initial damage, e.g., enzy-
matic removal of DNA base adducts, before they become irreversible mutations
as a result of DNA replication. This process is called mutation fixation. Initiated
cells show no recognizable biochemical or behavioral changes froiri their normal

BOX 2.5
Types of Genotoxicity
Genotoxic events play a definite a role in the following disorders:
• carcinogenesis, tumor formation

• developmental toxicity (heritable genetic diseases, malformations)
• other somatic diseases, such as arteriosclerosis and cataracts.
There are three different types of genotoxic effects, which are the result of changes
induced in the genetic material:
Gene mutation is the result of single or multiple base pair changes (substitutions,
deletions, insertions) in the DNA, which alter the information encoded in the
DNA's genome. Normally, the cell defense mechanisms can repair DNA damages,
recreating the original structure. Repair can be faulty, however, leading to her -
itable changes.
Chromosomal alterations may occur through damage by genotoxic agents, lead-
ing to structural aberrations (breaks, deletions, translocations), and through loss
or gain of one or more chromosomes and sometimes changes in the number of
chromosomes. Results of these changes might also lead to cell death or profound
genetic changes.
Gene rearrangements are characterized by altered gene expression (gene ampli-
fication, loss of activity). The underlying causes might he translocations or in-
versions of large parts of chromosomes.
contributed by A. Pinter, Johan Bela Institute, Budape.ct.
state, as the damage is not expressed as a new phenotype. However, the dam-
age will be converted to a permanent change unless the DNA is rapidly repaired.
Promotion A promoter is a substance that does not cause tumor development it-
self but which, by its action, transforms the initiated cell into an abnormal, ac-
tivated cell that may be the first cell of a tumor. This transformation results in
local cell proliferation leading to usually benign tumor formation. As with every-
thing in toxicology, dose and duration of exposure are key factors, so under cer-
tain circumstances, a promoter can also he tumorigenic in and of itself. At this
stage, the tumor is not yet malignant. Some tumors may be benign, but others
take the next stage of progression and become malignancies.
Progression In this stage, the tumor cells become malignant and the unrestricted
proliferation results in invasion of adjacent tissues and rnetastases. Metastases oc-
cur when cells from the tumor break off and arc transported elsewhere in the
body to give rise to new tumor masses. These may grow even more rapidly than
the original tumor, which is called the primary tumor.

The carcinogenic potential of a given agent is assessed primarily by human
epidemiology and experimental animal studies. Genotoxicological short-term
tests can also render data that might be helpful in assessing carcinogcnicity. In
1974, the International Agency for Research on Cancer (IARC) started to sys-
tematically assess the carcinogenic risk of substances and exposures to humans.
To date more than 500 evaluations have been carried out. The IARC's catego-
rization, based on the accepted evidence for carcinogenicity, is probably the most
widely recognized and widely used one by regulatory agencies. These categories
are listed in Table 2.4.
Examples of different groups of carcinogens are shown in Box 2.6. Most chem-
icals that cause cancer are organic, such as polycyclic aromatic hydrocarbons (B
naphthylamine, benzidine) benzene, his-chloromethyl ether, and nitrosamincs.
Most chemical carcinogens tested appear to act as electrophiles (electron-
deficient), which react covalently with nucleophiles (electron-rich) within the
target cell. Apart from alkylating agents such as sulfur mustard, N-methyl N-
nitrosourea, ethyl methane sulfate, and nitrosamides, chemicals often require en-
zymatic conversion to electrophiles. Even nitrosamides need hydrolyzing to ac-
tive alkylating agents. The conversion by enzymes provides one explanation for
the often tissue-specific nature of carcinogens, i.e., the necessary enzymes may
have low activity or be nonexistent in the unaffected tissues.
The variations in how individuals metabolize carcinogens may explain differ-
ences in susceptibility to cancer. One theory is that individuals can differ in their
rate of absorption from entry Site and/or in the mechanisms they have to repair
DNA, and that this could be responsible for the differences in risk experienced
by different individuals, families, or other groups.
Toxicity Testing in Experimental Animals

A large number of different tests are available to determine the toxicological profile
of a chemical. These tests may either assess acute, subchronic, and long-term toxi-
city or focus on specific areas of toxicity, covering a range of end points (see Table
2.5). The construction of the toxicclogical profile and the dose—response relation-
ship are the first stages in risk assessment, as will be discussed in Chapter 3. When
animal testing is used, the ethical issues associated with it must be considered.
Acute Toxicity Studies Acute animal studies are most commonly used to predict
human effects of short-term, high-lcvel exposures, such as may occur following an
TABLE 2.4
CARCINOGENIC CATEGORIZATION BY THE INTERNATIONAL AGENCY
FOR RESEARCH ON CANCER
Accepted Categories
1. There is sufficient evidence for carcinogenicity in humans
An agent is probably carcinogenic to humans
An agent is possibly carcinogenic to humans
There is inadequate evidence for carcinogenicity to humans
Not carcinogenic

BOX 2.6
Groups of Carcinogens
Organic carcinogens. Carbon-based compounds, as described in this chapter, that

cause cancer, usually by interfering with genetic material.
Inorganic carcinogens. Some compounds of arsenic, nickel, and chromium are
known to cause cancer. The mechanism of action, however, is not understood.
Asbestos and synthetic nuneralfibers. A variety of fibrous materials have been shown
to cause sarcomas in rodents when administered into the space between the lung
and the thoracic wall (e.g., asbestos, glass fiber, aluminum oxide). The dimen-
sions of the fiber and its durability in tissue appear to be related to its carcino-
genicity. Asbestos fibers also act as promoters and accentuate the carcinogenic
process initiated by cigarette smoke and other commonly encountered environ-
mental carcinogens. When inert plastics and metal films are implanted under the
skin of rodents they cause sarcomas. It may he that they stimulate the selection
of specific preneoplastic clones of cells that ultimately give rise to sarcomas. Like
fiber carcinogenesis, this seems to be unrelated to chemical composition.
Garcinogenesis by ionizing and ultraviolet radiation. Ionizing carcinogenesis and ul-
traviolet (UV) radiation—induced carcinogenesis are similar to chemical carcino-
genesis. X-rays and UV radiation damage DNA, inducing mutations, sometimes
as a result of inisrepatr.
Viruses. The role of viruses in human cancer has been the subject of intensive re-
search over the years. Viruses that induce cancer in animals include the mouse
mammary tumor virus, feline leukemia virus, and Rous sarcoma virus (RSV) in
chickens. Human viruses that might cause cancer include the hepatitis B virus
(liver cancer), human papilloma virus (cervical cancer), and Epstein Barr virus
(EBV) (nasopliaryngeal cancer and Burkitt's lymphoma), which can also cause
nonmalignant diseases such as mononucleosis.
accident, and these studies can provide a measure of the toxic potential of dif-
ferent compounds. Metabolic and pharmacokinetic studies arc used to determine
the absorption, distribution, and elimination of the test compound, its biotrans-
formation, and the rates in which these processes occur.
When toxicity is described in quantitative terms, the concepts lethal dose at
50% (LD 50 ) and effective dose at 50% (ED 50 ) are often used. The ED 50 is the
dose that would cause the effect in SO% of the lest population; the LD 50 is the
close that would kill 50%. The LD 50 or ED 50 is determined according to the
dose—response relationship. Lefhal doses by inhalation of chemicals in the form
of a gas or vapor can also he tested. In this case, the concentration of gas or va-
por that kills half the animals is known as the lethal concentration for 50% (LC50).
Although the LD 50 and the LC 50 only give information about the death of ani-
mals, they are very widely used as an index of toxicity. The criteria in Table 2.6
are often used for purposes of classification of acute toxic effects in animals.
The LD 50 and LC 50 are relatively reliable and in most cases correlate with lev-
els of human toxicity. However, they are not sufficient to fully characterize the
toxicity of chemicals, and it is impossible to assess health risks on the basis of

TABLE 2.5
RANGE OF TOXICITY STUDIES AVAILABLE FOR CONSTRUCTION
OF A TOXICOLOGICAL PROFILE
Study Comments
Acute toxicity Emphasis on acute effects and clinical signs, including lethality (LD 50 )
Suhchronic toxicity Often used to determine a dose without effect, generally of 28 or 90 days
duration; also referred to as subacute studies
Chronic toxicity Generally of approximately 2 years duration when rodents are used. May
be designed as carcinogenicity studies, chronic toxicity studies, or both
types combined.
SPECIALIZED STUDIES
Reproduction studies Multigenerational studies are used to investigate effects on reproductive

performance, effects on fertility, fecundity, prenatal and perinatal
toxicity, lactation, sweaning, and postnatal development and growth.
Teratology studies are used to investigate the ability to induce defects
during pregnancy and fetal/embryo toxicity.
Genotoxicity studies Investigation of the ability to induce mutations, chromosomal aberrations,
and other end points indicative of heritable genetic damage having
predictive relevance for carcinogenicity or the induction of inheritable
defects
Skin and eve To determine the effects of skin and eye contamination, e.g., in occupational
irritation tests exposure
Skin sensitization To investigate the potential to produce allergic sensitization
Immunotoxicity To investigate the specific effects on the immune system, e.g., on the
thyrnus, lymph nodes, hone marrow, and corresponding cellular and
hurnoral (antibody-producing) effects
Neurotuxicity To investigate the specific effects on the peripheral and central nervous
systems, e.g., with compounds known to be neurotuxic, such as
organophosphorous compounds. Also, behavioral toxicity tests may be
required to investigate neurotoxicity.
Inhalation To investigate the specific elfects on the lung and upper respiratory tract
or toxicity that occurs when the agent enters the body through the
litngs or pathogens of exposure that result from inhalation or any
con)hinatu)n of these. Inhalation studies are particularly challenging
to standardize and interpret
Adapied from Nicsink et al., 1996, with permission
LD 50 or LC 50 alone, especially for carcinogens. (For instance, we are not partic-

ularly interested in the dose that will kill 50% of the human population.) More-
over, the LD 50 and LC 50 give no information about the mechanism or type of
toxicity of the chemical or its possible chronic effects. Thus the LD 50 and LC 50
TABLE 2.6
CLASSIFICATION SYSTEM FOR ACUTE TOXIC EFFECTS IN ANIMALS
Oral LU50 Rat Dermal LU50 Rat Inhalation LU50 Rat
(mg/kg) or Rabbit (mg/kg) (mg/rn 3 hr)
Very toxic <25 <50 <500
Toxic 25-200 50-400 500-2000
Harmful 200-2000 400-2000 21,000-20,000

are very crude indices of toxicity. Other more specific tests give more specific in-
formation. One example of a specific short-term test is the short-term irritancy
test known as the Draize Test. The chemical being tcsted is applied to the animal's
skin, and the area is examined over the next few days for signs of a rash or flared
response. This test can also be carried out on the animal's eyes. (As noted be-
low, animal testing is now discouraged when other possibilities exist.)
Subchronic Tests In subchronic toxicity tests, animals are usually exposed re-
peatedly to a given chemical over a relatively long period (28 days or longer),
normally lO% of the lifetime of the selected animal. This means that inhalation
or ingestion studies last about 90 clays for rats and approximately 1 year for a
dog. Crude studies simply call for examination of the general condition of the
animals based on weight, food intake, activity and behavior, as well as exami-
nation of the organs for gross abnormalities to the naked eye. More sophisticated
studies include functional tests such as kidney and liver function, histopatho-
logical examination of organs and other tissues, and chemical analysis of blood
or urine samples.
Chronic Toxicity Testing The purpose of liletime or chronic bioassays is to de-

termine whether chemicals have any health effects that may take a long time to
develop. Cancer is often the long-term health effect of greatest concern, but other
effects on organs such as the kidney are also often studied. These studies are per-
formed by exposing animals, by ingestion or inhalation, to the chemical being
tested for the whole of the animal's lifetime. In rats, this may be 2 years; in mice,
a little less than 2 years. In a typical test, 50 mice or rats will be exposed to a
high but nonlethal dose of a chemical under study. The test animals are com-
pared throughout their lifetime with a similar number of contrcl animals. A good
study will expose different groups of animals of both genders to different doses
of the chemical. These studies may include very large numbers of animals and
are then referred to as megcimouse studies.
Reproductive Studies Studies in animals to check for adverse effects of a chemical

on any aspects of reproduction involve exposing one or both parents to the chem-
ical being tested, prior to mating, then observing the effects on any offspring. Some-
times just the pregnant female animal is exposed. Reproductive effects are classi-
fied according to whether the offspring are fewer in number, lower in birth weight,
or deformed or damaged in some way. Sometimes multigerierational studies may
he necessary to determine effects that may he passed on to future generations.
Other Types of Toxicity Testing

Each type of tcxicity testing has its OWn challenges and scientific problems. For
example, inhalation studies are among the most difficult studies to perform in
toxicology. It can be very challenging to control the exposure of animals and the
effects are often subtle or confined to certain tissues. Interactions are common
and extrapolation to human disease may be uncertain. As a result, large-scale in-
halation studies on animals are usually conducted in a small number of labora-
tories with proper equipment and experienced personnel.

Genotoxic Short-Term Tests Genotoxic activity of a given agent can be assessed
by short-term tests for gene mutation and chromosome alterations both in vitro
and in vivo. Over 50 tests have been developed over the last 20 years, of which
some 6-10 tests have been validated satisfactorily for the prediction of germinal
mutational effect and carcinogenic activity. The introduction of in vitro meta-
bolic activation systems, enabling the conversion of chemicals to nucleophilic re-
actives, has made the approach suitable to test a wide variety of chemicals. The
most commonly used and best-validated tests are the Salmonella revertent test
(AMES)lmammalian microsome test, the chromosome aberration in vitro test,
and the bone marrow cell test (chromosome aberration or micronucleus) in vivo.
Human Studies Information on toxic effects in humans can be obtained from ei-
ther clinical studies or epidemological studies that investigate health effects after
exposure in occupational settings or other environments. Clinical studies usually
focus on the detailed study of individual cases of disease, whereas experimental
studies are carefully controlled experiments in healthy humans, using low doses
otherwise considered to be safe. In view of the ethical aspects, only relatively mi-
nor and reversible health effects, such as subtle changes in reaction time, be-
havioral functions, and sensory responses, can be studied in experiments. Epi-
demiological research methods and the use in the health risk assessment process
will be discussed in Chapter 3.
Structure—Activity Relationships For many years it has been hoped that by ap-
plying knowledge of the physical structure and chemical characteristics of a
substance one could predict its biological activity. Much information has been
collected for various classes of compounds on the correlation between chemi-
cal structure, in terms of functional groups and special orientation, and para-
meters of toxicity. Short-term tests for assessing toxicity and maximum per-
missible concentraticns for occupational and ambient air pollutants have been
developed on the basis of such studies. However, the toxicological mechanism
of all chemical structures is not understood and there are many compounds
that do not react as expected, based on the structure—activity relationship. At
the current level of knowledge, structure—activity relationships are useful indi-
cators of potential toxicity and may hell) to priorize toxicological research, but
they require corroborating evidence and should not be relied on solely in the
decision-making process.
Information on Toxicity
Product identity is, of course, crucial in hazard identification. A product may have
a common trade name that is used for advertising and marketing purposes. The
Chemical Abstracts Service (CAS), a section of the American Chemical Society, as-
signs a CAS registry number to every chemical. Most product information sheets
contain CAS numbers, which are useful in researching the toxicity of the chem-
ical in question. The Registry of Toxic Effects of Chemical Substances (RTEC) number
is also important, as it is linked to a list of scientific articles on the health effects
of chemicals. This registry is operated by the National Institute for Occupational
Safety and Health (NIOSH) in the United States.

TABLE 2.7
TWO CLASSIFICATION SYSTEMS FOR HAZARDOUS CHEMICALS
Canadian Categories of
Controlled Substances Categories of Dangerous Substances
as Defined by the Council Directive of
Class Definition European Communities
A A compressed gas Explosive
B Flammable and combustible material Very toxic/toxic
C Oxidizing material Oxidizing
D Poisonous and infectious material Extremely flammable/highly
Dl Immediate and serious Flammnable/Ilammable
D2 Other toxic effects Haritiful
D3 Biohazardous Corrosive
E Corrosive material Irritant
F Dangerously reactive material Sensitizing
Carcinogenic/rnuiagenic
Toxic for reproduction
Dangerous for the environment
Right-to-know legislation in many jurisdictions has helped considerably in the

identification and control of hazards. In Canada, for example, the Workplace Haz-
ardous Materials Information System (WHMIS) requires provision of Material Safety
Data Sheets (MSDS) on every substance, the labeling of controlled products ac-
cording to categories as listed in Table 2.7, and the training of workers in the un-
derstanding of the MSDS and appropriate use of the substances. Similar legisla-
tion exists in many other countries, but certainly not all jurisdictions. in the
countries of the European Community, several signs and sentences indicating the
potential risk (R sentences) and safety precautions (S sentences) are used and it
can be expected that these will be used increasingly in other European countries
as well. Combinations of different R and S sentences provide adequate safety pre-
cautions for handling hazardous substances and prepa rations.
All the above information is usually supplied as a precondition for marketing
in most countries. An example of an tnternational Chemical Safety Card is shown
in Figure 2.6. These cards are published by the tPCS and are available in many
languages for more than 1000 chemicals.
PHYSICAL HAZARDS
Types of Physical Hazards

Physical hazards are forms of potentially harmfttl energy in the environment that
can result in either immediate or gradually acquired damage when transferred
in sufficient quantities to exposed individuals. Physical hazards may arise from
forms of energy that occur naturally or are anthropogenic. A variety of different
energy types can pose physical hazards, for example, sound waves, radiation,
light energy, thermal energy, and electrical energy. Mechanical (kinetic) energy,
which results in injury when a sufficient amount is transferred to an individual,
will be discussed separately in Mechanical Hazards, below. The release of phys-

NITROGEN DIOXIDE ICSC: 0930
HAZARD SYMBOLS
CASk 1010244-0 Nitrogen peroxide Consult national legislation
RTECS# OW9800000 (cylinder)
ICSC# 0930 NO 2
UN# 1067 (liquefied) MoFecular mass: 46.0
EC# 007-002-00-0
TYPES OF HAZARD ACUTE HAZARDS SYMPTOMS PREVENTION FIRSTAIO, FIRE FIGHTING
Not combustible but enhanses NO contact with all combustible Shut off supply it not possible and
FIRE combustion of other substances materials including clothing. no risk to surroundings, let the fire
Supports combustion of carbon, burn itself out: in other cases
pI'iosphorus and sulfur, exsnguish with powder. dry chemical
Elevated temperature may In case of fire: keep cylinder cool by
EXPLOSION spraying with water, Combat fire out
cause cylinders to explode,
of sheltered posit ion
EXPOSURE IN ALL CASES CONSULT A DOCTORI
Cough, headache. nauxea: symptoms Ventilation, local exhaust. Fresh air, rest, half-upright position,
Inhalation and refer for medical attention
may be delayed: see Notes or breathing protection
Protective gloves, protective Remove contaminated clothes, rinse
Skin Redness clothing when liquefied gas. and then wash skin with water and
soap, and refer for medical attention.
Safety goggles, or, when First rinse with plenty of water for several
Eyes Redness. pain, liquefied gas, face shield, minutes (remove contact lenses if easily
or eye protection in combination possible), then take to a doctor
with breathing protection
Do not eat. drink, or smoke

ngestion during work.
SPILLAGE DISPOSAL STORAGE PACKAGING AND LABELLING
Evacuate danger area, consult an expert, ventilation Separate from combustible. UN baz class: 2.3
use water spray to knack down vapour, neutralize organic oxidizable substances: UN subsidiary risksi 5 1
running water with chalk or soda, do NOT absorb in ventilation along the floor.
saw-dust or other combustible absorbents (extra FURTHER INFORMATION ON LABELLING
personal protection: complete protective clothing Consult national legislation
including self-contained breathng apparatus).
PHYSICAL STATE. APPEARANCE ROUTES OF EXPOSURE

REDDISH BROWN COMPRESSED LIOUEFIED The substance can be absorbed in the body by inhalation
GAS OR YELLOW FUMING LIOUID.
WITH PUNGENT ODOUR. INHALATION RISK:
A harmful concentration of this gas in the air will be
PHYSICAL DANGERS - reached very quickly on loss of corfarninent
The gas is heavier than air,
0 EFFECTS OF SHORT-TERM EXPOSURE
CHEMICAL DANGERS: The substance irritateu the eyes, the skin and the respiratory
The substance decomposes on heating above 160 tract Inhalation of this gas may cause lung oedema. (see
producing nitric oxide and oxygen which increases fire Notes). the substance may cause delayed effects on lungs.
2 hazard, The substxnce is a strong oxidant and reacts
violently with combustible and reducing materials EFFECTS OF LONG-TERM OR REPEATED EXPOSURE
- Reacts violently with anhydrous ammonia, chlorinated The substance may have effects on the lungs Accxlerating
hydrocarbons, petroleum, ordinary fuel and rocket fuel, capacity was seen in a group of lung-tumor susceptible mice
Reacts with water forming nitric acid and nitric oxide.
Reacts with alkalie to form nitrates and nitrites.
Attacks many metals in the presence of moisture
OCCUPATIONAL EXPOSURE LIMITS (GELs):
TLV: 3 ppm: 56mg/rn 3 )ACGIH 1990- 1991(
P0K - 2 mg/m 3 (USSR 1984)
PHYSICAL Roiling point. 21 'C

PROPERTIES Melting point: -9 3C
Relative density (water = 1): 1.45 (liquid)
Solubility in wxter reaction
Vapour pressure, kPa at 20CC. 96
Relative vapour density (air = 1): 1,58
ENVIRONMENTAL
DATA
NOTES
The commercial brown liquid under pressure is called nitrogen tetroxide. Transport Emergency Card,
Actually this is an equilibrium mixture of NO2 and the colourless N 2 0 4 TEC (R(-109
Nonirritunt concentration may cause lung oederna. The symptoms of lung
oedema sometimes do not become manifest until 24 -36 hours have passed NFPA Code: H 3: F 0 R 0 ray
and they are aggravated by physical effort. Rest and medical observation are
therefore essential. Turn leaking cylinger with the leak up to prevent escape
of gas in liquid state. Corrosive to steel when wet, but may be stored in steel
cylinders when moisture content is 0_1 1/, or lens
Figure 2.6 International chemical safety card. Source: International Program on Chenii-
cal Safety, WHO, Geneva.

ical energy may be sudden and uncontrolled, as in an explosive loud noise, or
sustained and more or less under control, as in working conditions with long-
term exposure to lower levels of constant noise.
Noise, radiation (including light), and temperature factors are the most com-
mon examples of physical hazards. They can cause health effects in natural ex-
posure situations, such as when ultraviolet (UV) radiation from the sun causes
eye cataracts or when heat waves kill the frail, the young, and the elderly. For
environmental health management, human-made exposure situations are of the
greatest importance, such as the loud noise that millions of people are exposed
to in their workplaces. Other examples include the ionizing radiation isotopes
spread from the accident at the Chernobyl nuclear pocr plant, which exposed
5 million people to excessive doses and made large land areas uninhabitable for
many years.
Noise and Vibration
Noise is defined as an unwanted sound. Sound travels as waves in air (or pres-
sure changes) that make the eardrum vibrate. The eardrum passes these vibra-
tions on to three bones in the middle ear, which in turn pass the vibrations to
the fluid contained in the cochlea (in the inner ear). Within the cochlea are tiny
nerve endings commonly known as hair cells. They respond to the fluid vibra-
tions by sending neural impulses to the brain, which then interprets the impulses
as sound or noise. Intense sound produces higher-amplitude waves than less in-
tense sound. The intensity of a sound is determined by the height (or amplitude)
of a sound wave. Higher waves carry more energy and produce greater vibrations.
These higher waves produce greater vibrations within the ear, which can damage
the hair cells. Sometimes the damage is temporary and is naturally repaired after
a few minutes or days. The ringing in the car that one experiences after attending
a loud music concert is a common symptom of this temporary damage. At high
noise intensity, however, the damage is permanent because hair cells, like all nerve
cells, cannot be replaced and have very limited capacity to repair themselves. Each
year, millions of industrial workers lose significant proportions of their hearing ca-
pacity because of high noise exposures in their workplaces. High noise levels may
also occur in the general environment, but mainly in conjunction with traffic and
transport systems. The noise level on a sidewalk of a busy street or in a speeding
subway train with open windows can reach levels that may damage hearing.
At lower intensity levels, noise can cause disturbed sleep, stress, and reduced
well-being. The problem of community noise and its disturbance effects is in-
creasing, as more and more people live in cities where noise from traffic, neigh-
bors, and industry is seldom brought under any control—at least not at the first
stages of urbanization. Increasingly, as a result of community protests against the
noise, sound protective barriers are being erected along motorways and railways.
Sound intensity is measured in decibels (dB). The sound intensity is deter-
mined by the changes in the pressure of the sound wave. The intensity of a sound
observed by the human ear also depends on the freqtiency or tone of a sound.
The frequency is determined by the number of sound waves per second and is
expressed in Hertz (1 Hz equals 1 sound wave per minute). Therefore, sound lev-
els are commonly adjusted to the observation of the human car, i.e., using the

TABLE 2.8
SOUND LEVELS OF SOME FAMILIAR SOUNDS
Sources Aural Effect Sound Level dB(A)
Shotgun blast Human ear pain threshold 140
let Plane (at take-oil)
Firecrackers, exploding
Rock music, amplified Uncomfortably loud 120
Hockey game crowd
Thunder, severe
Pneumatic jackhammer
Powered lawn mower Extremely loud 100
Tractor, farm type
Subway train, interior
Motorcycle, snowmobile
Window mounted air conditioner Moderately loud 80
Crowded restaurant
Diesel powered truck/tractor
Singing birds Quiet 60
Norntal conversation
Rustle of leaves Very quiet 20
Faucet dripping
Light rainfall
Whisper Just audible 10
"A" scale: dB(A). Sound intensity is measured by an instrument called a sound

level meter. Table 2.8 outlines some familiar sounds and their dB(A).
Increasing sound intensity increases the risk of hearing loss. Risk of incurring
hearing loSs begins with prolonged exposure to sound of approximately 75 dB(A)
(WHO, 1980a). Many countries use 85 dB as the noise safety limit in workplaces.
As a rule of thumb, if a loud voice is not understandable at a distance of 1 me-
ter because of excessive background noise, the background noise level is above
85 dB and likely to be dangerous. Even if the sound level is not noticeably un-
comfortable, hair cells in the inner ear can be damaged. As intensity increases,
the length of exposure time that causes hearing loss decreases. For example, ap-
proximately 15% of individuals exposed to 90 dB(A) for 8 hr per day during a
whole working life (40 years) will experience significant hearing loss. At 85 dB(A)
the risk is 10%.
Noise-induced hearing loss can be prevented by a program of both noise con-
trol and monitoring of workers for early detection of hearing loss by looking for
the temporary threshold shift and implementing changes before hearing loss be-
comes permanent. Noise control is a highly technical specialization that may in-
volve acoustical engineering, plant design, engineering controls, and containment
or isolation of noise sources. However, most problems involving excessive noise
can be handled effectively and inexpensively using basic principles.
Hearing conservation programs should include regular monitoring of the
workplace, baseline and annual audiograms for all exposed workers, in-service

BOX 2.7
The Basics of Radiation
The atom is the simplest unit into which matter can be broken down yet still retain
its identity as a distinct element, including all of its chemical characteristics. Each
atom consists of two components: a nucleus (containing protons and neutrons) and
orbiting electrons. The number of protons in the nucleus of the atom, also indicated
as the atomic number, determines the identity of element. There is an equivalent
number of electrons in the atom unless it is ionized or incorporated into a molec -
ular bond. The atomic number determines the chemical characteristics of the ele-
ment—how many electrons, how they are arranged, and how atoms of the element
bond to one another and other elements.
Unstable atoms, which possess too many or too few neutrons, try to become
more stable by emitting particulate and/or electromagnetic radiation (energy). The
type of radiation emitted (alpha, beta, or gamma radiation) depends on the type of
instability. When alpha or beta particles are emitted, the atoms of one element ac-
tually convert to atoms of another element. The emission of radiation from an un-
stable atom is called decay or disintegration. Each type of unstable atom has a known
half-life, which represents the length of time required for half the atoms to decay,
to emit radiation. Examples of half-lives are as follows:
uranium-238 4.5 billion years

p1 utoni urn -239 24,390 years
cesium- 137 30 years
strontium- 90 29 years
tritium 12.5 years
iodine- 131 8.5 days
radon 3.8 days
A unit of radioactivity is called a hecqucrel (Bq). It is equivalent to one atom decay-

ing per second. The amount of damage caused by this radioactivity depends on a
number of factors, especially the radiation type and the actual dose, measured as
Gray (Gy) or Sievert (Sv). The types of radiation can be broken down as follows:
Alpha radiation. An alpha particle is a heavy particle (actually a helium nucleus)

with a charge of +2, which gives up energy in short distance, mostly through
ionization. It is not very penetrating and is easily shielded against when the source
is external to the body. For instance, alpha radiation cannot penetrate the skin
surface. However, when particles emitting alpha radiation are inhaled or ingested,
they can ionize atoms in living cells, leading to signilicant damage.
Beta radiation. This radiation is the result of the emission of electrons from the
nucleus. Electrons are smaller and lighter than alpha particles and also pose a
hazard if the source is inhaled or ingested. Compared to alpha radiation, it has
a higher penetration (depending on energy and density of the material) but has
a lower rate of ionization than alpha radiation. Usually beta radiation is shielded
against by using plastic or light metals because it can produce gamma radiation
when passing through lead, which is often used for shielding against radiation.
Gamma radiation. This radiation is a form of electromagnetic energy emitted from
the nucleus, often together with emission of beta particles. This electromagnetic
radiation with high energy and frequency can penetrate relatively easy but has
a lower rate of ionization. Both internal and external sources can pose a hazard.
IVUNUIUIIRt

(W/ltiflucd)
For example, X-rays are machine-made gamma rays, whereas cosmic rays are
gamma rays from space.
4. Neutron radiation. Free neutrons can he a form of radiation when they are re-
leased from the atomic nucleus. They can induce significant cell damage by ion-
izaflon because the heavy particle carries a high amount of energy. Material
through which they pass may become radioactive, absorbed by nuclei of atoms
in the material, which then become unstable and decay themselves; this is called
neutron activation.
and preservice worker education regarding hearing conservation, systematic

record keeping, worker notification when problems are detected, and the provi-
sion of hearing protection to all exposed workers. Many programs in industry
include referral of affected employees to specialists, administrative controls to
limit the duration of assignments in noisy areas, and noise control measures. (As
an example of a risk management strategy, a workplace-based hearing conser-
vation program will be described in Chapter 4.)
In addition to noise, which can be regarded as a vibration transmitted by air
to the ear, vibration energy can also be transmitted directly to other parts of the
human body. The use of many tools or hand equipment can result in adverse
health effects as a result of arm and hand vibration. The most characteristic ef-
fect of prolonged exposure to vibration of the hand is vibration vasculitis, or white
finger disease, a form of spontaneous or cold-induced blood vessel constriction that
results in reduced sensatitn to fine touch, vibration, or temperature, and causes
marked pain. It is named for the white appearance of the fingers when the blood
vessel constriction occurs. Vibrations can also be transmitted to the entire body
when driving vehicles like bulldozers, excavators, trucks, and cars on rough lands
or bumpy roads. These vibrations may damage the musculoskeletal system.
Ionizing Radiation
Radiation hazards can be divided into those from ionizing and nonionizing radi-
ation. (Nonionizing radiation and light as one specific form of nonionizing radi-
ation are discussed in Noniodizing Radiation, and Light and Lasers, below.) The
basic principles and the different types of radiation are described in Box 2.7. Ion-
izing radiation emerges when an electron is removed from a neutral atom and a
pair of ions are produced—a negatively charged electron and a positively charged
atom. It is the ionizaticn of atoms in the human body that causes harmful bio-
logical effect. The ions are highly reactive and damage critical cell structures, in-
cluding proteins and DNA. Ionizing radiation is, in fact, defined as electromag-
netic radiation (see next section for definition) with sufficient energy to displace
an electron from an atom.
Knowledge about the nature and probability of adverse health effects of ion-
izing radiation is based on animal experiments and observations of the effects of
human exposures at high doses, such as the studies of survivors of the atomic
bombings of Japan and of people exposed in radiation accidents. Studies of pa-
tients exposed to radiation for medical treatment as well as occupational health

studies have also demonstrated important effects (e.g., miners exposed to radon
have been found to have a higher incidence of lung cancer). The effects of ion-
izing radiation are divided into two basic types; threshold effects (also known as
nonstochastic, or deterministic) and nonthreshold effects (stochastic) The nonstochastic
effects follow a dose—effect relationship in a single individual, as in the ingestion
of a toxic substance (see Chapter 3, Relationship Between Dose and Health Out-
come). Stochastic effects occur as an all-or-none outcome with a certain proba-
bility following exposure. For example, following exposure to high levels of ra-
diation, a person may have a high risk of developing cancer but any one person
will not get more of a cancer with higher exposure.
Exposure to radiation from natural sources, such as cosmic radiation, and in-
door exposure, including radiation from building materials and radon exposure,
account for more than half of the annual dose people usually receive. The total
dose depends on the geographical area where people live. In addition to the nat-
ural background radiation, people can be directly exposed to ionizing radiation
during medical treatments, for instance, radiation therapy for cancers and X-rays
for imaging of internal organs. Strict precautions have to be taken to protect both
patients and hospital staff. The health risk as a result of medical application of
ionizing radiation can be kept at a minimal and acceptable level. Some consumer
articles also contain minute amounts of radioactive materials, such as smoke de-
tectors, light switches, or illuminating watches and clocks. The contribution of
these sources to the total background exposure is very low (<0.5%). Other
sources of ionizing radiation are nuclear accidents (Chcrnobyl), nuclear testing,
and nuclear power plants. There arc many nuclear power stations in different
countries around the world, and in some countries they produce the bulk of elec-
tricity used in the country (e.g., France). Again, strict precautions need to be
taken to prevent accidents, but when an accident happens, as in Chernobyl, the
health effects can be very serious. The causes and consequences of the accident
in Chernobyl will be discussed in Chapter 9.
When people incur exposure to high doses of radiation that exceed a certain
threshold, the deterministic health effects include skin burns, damage to the bone
marrow, sterility, acute radiation sickness, and death. These effects have been
observed in atomic bomb survivors, patients treated by radiation, and in work-
ers accidentally overexposed, as in the case of workers at the Chernobyl power
station at the time of the accident. The effects occur at doses of a few tenths of
Sieverts (Sv), the common measure that takes into account the absorbed dose and
the type of radiation. (It replaces the old unit called a rem; 1 rem = 0.01 Sv). The
deterministic effects occur at doses much higher than those that would occur to
workers in normal operations or to the public from normal environmental dis-
charges from nuclear power production, in which case, doses may be in the or-
der of millionths of a Sievert (i.e., microsievcrts). The stochastic or nonthreshold-
related effects, including cancer and genetic effects, are believed to occur as the
result of low as well as high doses.
The basic question in assessing this risk for workers and members of the pub-
lic concerns the nature of the dose—response relationship at low doses and dose
rates. According to the International Commission on Radiclogical Protection
(ICRP), it is prudent to regard the dose—response relationship for cancer risk from

radiation as linear down to zero dose. The probability of the occurrence of fatal
cancers over a lifetime in a population exposed to radiation at low doses has been
estimated by the ICRP to be about 5/100 per person-Sieverts; or if 100,000 peo-
ple were exposed to a dose of I mSv each, then 5 would die of cancer. The can-
cers of greatest concern with respect to radiation are lung cancer, leukemia, and
cancers of the skin, breast, and thyroid. Generally, there is a long latency: ap-
proximately 5 years for thyroid, 10 years for leukemia, and 20-30 years for the
other cancers. The human embryo and the fetus are particularly sensitive to radi-
ation, and the risk of cancer induction is likely to be higher for fetuses than in the
general population, while the risk of genetic damage is probably at least as high.
As a result of the observation of malformations in animal studies, it is recommended
that occupational exposure of pregnant women be controlled such that the dose
to the fetus does not exceed 1 mSv during the course of the pregnancy.
Radon is a gas present in rock, groundwater, and soil in some geographic ar-
eas. It is a product of the natural decay of radium, a solid material found in the
earth's crust in many locations. It has been linked to increased lung cancer in
miners (particularly uranium miners). It can seep into basements of houses and
expose the inhabitants. There is increasing concern that residential radon may
also he contributing to an increased risk of lung cancer in some countries (see
Chapter 4).
Nonionizing Radiation
All forms of nonionizing radiation are part of the electromagnetic spectrum. Elec-
tromagnetic radiation is a form of energy that consists of an electric and a mag-
netic component. The energy is transported by the propagation of disturbances
in electric and magnetic fields that are always at right angles to each other. The
two fields vary in phase with one another in the form of a wave motion.
The waves travel at the speed of light, which is in vacuum approximately 3
io rn/sec. Figure 2.7 shows the complete electromagnetic spectrum, which spans
from wavelengths shorter than 10 1 ° ( gamma rays) meter to longer than 1 me-
ter (up to 100 km) for radiowaves. Electromagnetic radiation with a wavelength
above 10 10 meter does not have enough energy to cause ionizations. Therefore,
this part of the spectrum is referred to as nonionizing radiation.
As indicated in Figure 2.7, nonionizing radiation includes UV radiation from
the sun, which can cause eye cataracts that in turn can lead to blindness, as well
as skin cancer and immune system damage. In recent years, there has been con-
siderable concern about this hazard, because the depletion of stratospheric ozone
layer has led to an increase in UV radiation exposures (see Chapter 11 and WHO,
1994a). Another type of nonionizing radiation to which millions of people are
exposed is electromagnetic fields (EMF). These develop around electric power lines,
electric machinery, electric installations in home radio transmitters, and portable
telephones. In most situations the doses are too low to cause any adverse health
effects. However, a number of suspected adverse health impacts, including can-
cer, have been reported, but research data have not given a clear picture yet.
Light is in itself a type of radiation that can cause blindness if the eye is directly
exposed to very high—intensity light, such as when a person looks straight at the
sun for too long (see Light and Lasers. below).

name and approximate frequency (Hz) wavelength (m) Length units
range of radiation
1022 10-13
y-rays -1021 1012 picometer (pm)
-1020 10-11
X-rays 10-10
- 10 19
- 10 10 -s nanometer (nm)
-1017 10 -s
-1015 10 -i
- 10 15 10 -6 micrometer (jm)
-1014 10 -s
infrared -1013 10 -a
-1012 10 -s millimeter (mm)
t
microwaves
-1011
-1010
10 -2
10-1
- 10 1 meter (m)
I
- 10 8 -101
- 10 102
-106 - 10 kilometer (km)
- 10 10
radiowaves
- 10
10
Figure 2.7 Range of the electromagnetic spectrum.
Exposure to UV radiation occurs mainly from sunlight, but it can also occur
from electric welding arcs and from UV lights used in laboratories. Sunlight con-
tains UV-A, UV-B, and UV-C, but normally only UV-A reaches the earth's sur-
face in significant amounts. UV-B and UV-C are more damaging to health but
they are normally reflected away from the earth by the stratospheric ozone layer.
In case of damage to the ozone layer, which has now been shown to occur be-
cause of contamination of the atmosphere with chiorofluorocarbon (CFC) chem-
icals, people may be exposed to an increasing intensity of UV-B. UV-C does not
reach the earth's surface.
The most well-documented health effect of UV radiation exposure is skin can-
cer. People with light skin are at greater risk, particularly if they work outside in
occupations that do not provide much protection from the sun. An example is
the very high risk of skin cancer among outdoor workers (including farmers) in
Australia and New Zealand. Excessive sun-bathing is another exposure that adds
to the risk of skin cancer. Skin cancer is now becoming increasingly common in
countries with light-skinned people, such as the United Kingdom and Scandi-
na via.
Another important health effect of UV radiation is cataract (lens opacity) of
the eye. Cataracts may lead to blindness and are increasingly common at older
ages. This effect is caused by direct exposure of the lens to UV radiation. In In-

dia, for example, many farmers work in the fields in the blazing sun all day long
without wearing any protection of the eyes. In this country alone, 2 million peo-
ple develop blindness each year; half of these cases are caused by cataracts. Ul-
traviolet ray—related cataracts are not dependent on skin color, so this health ef-
fect may be even more critical in tropical countries than in Europe. The intensity
of UV radiation at ground level in tropical areas, on average throughout the year,
is many times greater than that in temperate areas (e.g., Europe).
A third potential health effect of UV radiation is changes in the immune sys-
tem, but so far this has only been demonstrated in animals. If high UV exposure
reduces the function of the immune system in people, it could increase the oc-
currence of infectious diseases in exposed people, and it could decrease the ef-
fectiveness of immunizations against communicable diseases, such as measles and
hepatitis, in children. Currently, we do not know if this is a real problem.
Concern about exposure to EMF has been raised by studies that suggest a
small increased risk of cancer with prolonged exposure. As mentioned earlier,
exposures occur close to high-voltage power lines, particularly near the above-
ground power lines with super-high voltages, which have become increasingly
common in recent decades along with the use of electrical appliances in the home
and the increasing presence of electricity in urban life. Exposure can also occur
in homes with electric wiring systems of a particular type and in workplaces
where electric machinery is placed in close proximity to workers. There is not
sufficient scientific evidence to support a definitive statement about whether EMF
is an important health concern. Nevertheless, in many countries, limit values
have been set for exposure to extremely low frequency fields.
Light and Lasers

Visible light is one type of nonionizing radiation. It is not as powerful as UV ra-
diation and mainly causes damage to the eye after overexposure. Laser (which
stands for light amplification by stimulated emission of radiation) is light that has
been synchronized such that the radiation is of one specific frequency and the
light waves are all traveling in phase in pulses. This delivers much larger energy
directly to the eye than normal light. Laser light of high energy can therefore he
extremely damaging to the eye and can even burn the skin or other materials.
Although laser light is an occasional hazard in occupational settings, the lack of
sufficient lighting, particularly in the work environment, is a much more gen-
eral problem. Poor lighting increases the risk of injuries in factories as well as on
roads, and increases eye strain in people who have to read or perform precision
tasks in their work. Eye strain can led to headaches and various psychosomatic
symptoms. The lighting needed for fine tasks increases significantly with age, be-
cause of the natural deterioration of eyesight with age. A 40-year-old person
needs twice as much light as a 20-year-old person to see an object with the same
clarity. However, because lighting consumes energy and this increases costs, many
factories and homes are poorly lit, especially in poor countries.
Pressure
Barometric pressures above or below one atmosphere (the normal pressure at
sea level) are part of the conditions of work in special environments, such as un-

der water or at high altitude. The absolute pressure is usually less critical than
the changes experienced by the worker. The direct adverse effects of these pres-
sure changes are called barotraurna and are of particular interest in aerospace and
undersea medicine. There are also a number of problems that result from the
dissolving of gases into body fluids or, conversely, the release of gases out of body
fluids.
Health problems associated with compression generally occur only when there
is no way to equilibrate pressures in an enclosed space. Decompression effects
are more common and can be severe as a person emerges from a pressurized en-
vironment. They occur when a diver returns to surface too quickly or when work-
ers who are in compressed chambers, such as caissons, have been depressurized
too abruptly. All commercial and amateur divers are instructed in the use of div-
ing tables, a set of graphs and tables that provide guidelines for ascent after div -
ing to a given depth and remaining there for a given period of time. Failure to
adhere closely to these tables, through inattention or during an emergency, may
result in potentially serious effects, including decompression sickness, air emboli,
and aseptic necrosis (death of small areas) of bone.
Effects associated with ascent to high altitude and reduced barometric pres-
sure are dealt with in the literature of aerospace medicine and are too highly
specialized and uncommon to describe here in detail. However, it should be re-
membered that already at 2000 meters altitude the reduction of oxygen pressure
by inhaled air can cause shortages of breath in people not accustomed to this al-
titude, and above 4000 meters nausea and unconsciousness may occur unless
precautions are taken.
Extremes of Temperature
Hazards associated with extremes of temperature can be divided into exposure
to heat and exposure to cold. In most countries, the climate changes from cold
to warm once a year, or a change in seasons brings torrential rainfall or hurri-
canes. Heat and cold affect the well-being and health of millions of people each
year. Adaptation to the climate, and type of housing, clothing, and other pre-
cautions will determine the impact on health.
Internal temperature regulation in the presence of temperature variation in
the environment is necessary for human life. Problems arise when one of three
conditions occurs: (1) temperature variations are so extreme that they exceed
the considerable ability of the body to adapt; (2) mechanisms of adaptation, such
as vasodilatation or sweating, arc impaired; or (3) exposure to extremes of tem-
perature is concentrated on a particular body part, as in frostbite or thermal burns.
The human body regulates temperature through the central nervous system from
a control center in the hypothalamus, a small structure in the center of the brain.
This center receives neural impulses from thermal receptors on the skin and re-
ceptors sensing the temperature of blood in deep body structures. It responds by
activating mechanisms controlled by the autonomic nervous system that dissi-
pate heat (vasodilatation and sweating) or that increase the internal generation
of heat (shivering) and conserve heat (vaso). It also sends signals to the cortex
of the brain that make one aware of being hot or cold, initiating behavioral
changes, such as changes in dress, seeking shelter, or modifying activity. This

center can become disoriented from factors including infection, vasodilation as-
sociated with alcohol and autonomic dysfunction, or potentially lethal extremes
in bodily temperature, and as a result, it prompts inappropriate responses.
The body regulates average temperature in the deep body within a narrow
range centered on about 37°C. Although core temperature is maintained ap-
proximately constant, there is continuous variation in the heat flux needed to
maintain this constancy in the body. Heat is generated by metabolic processes
and by work performed by the muscles. Heat is also taken into the body from
the environment if the external temperature is warmer than the body core. Heat
is lost to the environment by four means: radiation from the surface of skin (as
infrared radiation), evaporation in the form of sweating, conduction by contact
with a cooler surface, and convection by air movement carrying heated air away
from the surface of the skin or expired air from the lungs. Expired air from the
lungs is saturated with water vapor and is therefore able to carry much more
heat than dry air, so it is another mechanism of heat loss through evaporation
and convection. Heat cannot be lost as efficiently from the body when there is
interference with these mechanisms. Radiation and conduction may be reduced
by insulation, as with padded clothing, which reduces evaporation and convec-
tion, thus restricting air circulation close to the skin. Evaporation is also reduced
when humidity of the air is elevated. In contrast to horneostatic temperature reg-
ulation, perception of heat and cold is highly subjective and a matter of individ-
ual preference. Current norms and standards for heat and humidity are based on
comfort for the largest proportion of workers but may be perceived as uncom-
fortable for some.
Cold is particularly dangerous because it may also reduce awareness of an in-
jury. Temperature and air movement, called windchill, can severely affect and
even kill a person who is not properly protected. Both severe heat and severe
cold are particular hazards for the very young and very old. Local cold damage
results in frostbite while cold affecting the whole body results in hypothermia.
Frostbite is the local freezing of tissue that may result in irreversible damage. Ex-
tremities such as fingers, toes, and the tips of ears and noses are particularly vul-
nerable. Amputation of the affected area may be required in severe cases. Hy-
pothermia is the condition of low body temperature. It is usually fatal if not
recognized and treated by warming the patient.
Extremes of heat can also have local or systemic effects. Local heat can result
in burns. Less extreme but prolonged heat results in systemic effects such as heat
stress, a problem that is not limited to tropical climates or jobs involving prox-
imity to a heat source. It can also occur as the result of excessive heat retention
due to the combination of heavy clothing and strenuous exercise or in combi-
nations of heat and humidity that interfere with evaporative cooling. Evapora-
tion or artificial cooling must balance the heat gained from convection and ra-
diation when the surroundings are hotter than the person. If heat loss does not
equal heat gain and heat generation, then heat accumulates and the core tem-
perature rises.
There are several medical conditions that can develop as a result of heat stress.
Of these, heat stroke is the most serious. This potentially fatal condition occurs
when a person can no longer adapt to the heat and collapses with failure of the

circulation. It may occur in the workplace in jobs where exposure to intense heat
is uncontrolled. Heat stroke is more common among people who are not used
to heat and is most likely to occur during occasional heat waves, especially in
cities. As a consequence of increasing urbanization, nriore and more people are
living in urban agglomerations where heat can accumulate during sunny, hot
periods. Cities are usually warmer than the surrounding countryside and are of-
ten more humid. In unprotected populations, heat stroke may occur during heat
waves, especially when it is very humid. The resulting fatalities occur most of-
ten among the elderly, the chronically ill, and people who are not eating well or
drinking enough fluid. Compounding this is the fact that peaks of air pollution
from car exhaust and ozone production at ground level often coincide with heat
waves because they often occur during the summer months. The combination of
air pollution and extreme temperatures can be serious. Heat in the workplace
and general environment also has an effect on work capacity. Traditional meth-
ods of house construction in hot countries are largely effective in protecting
against the hazards of extreme heat, but modern house building methods may
require air conditioning or artificial cooling systems, and when these systems
break down or cannot be afforded, people are at increased risk.
Localized extreme heat resulting in burns can occur in variety of ways. Direct
exposure to fire results in many serious burns, but contact with hot substances
is also very common. Hot substances include liquids (common during cooking),
hot solid objects such as stovetops or machinery, or hot gases. More house fire
deaths occur due to suffocation from smoke inhalation than from burn injury.
Nevertheless, burn injuries both at work and in the community are important
causes of morbidity and mortality. Burns that occur at home will be discussed in
Home and Recreational Injuries, below. Burns can also be the result of exposure
to electrical hazards, which occur both in the workplace and in the community.
Most deaths from electrocution occur immediately at the scene as a result of car-
diac arrest. Victims who survive are at risk of significant disability, as loss of limb
frequently results, especially following high-voltage contact. Injuries that do not
seem very serious initially can worsen progressively over 2-4 days, manifesting
damage to deeper tissues.
MECHANICAL HAZARDS
Understanding Mechanical Hazards

Mechanical hazards are those posed by the transfer of mechanical or kinetic energy
(the energy of motion). The transfer of mechanical energy can result in imme-
diate or gradually acquired injury in exposed individuals. The terms injury and
trauma are often used interchangeably to refer to the harm that may result from
mechanical hazards. The events and circumstances that result in injury have corn-
monly been referred to as accidents. This term is no longer used by those work-
ing in injury control. In many languages it implies that injuries are random, un-
predictable, chance types of events. Environmental health specialists believe that
most injuries are predictable and preventable, and can be studied using epi-
dcmiological methods, just like any illness or health effect.

Cultural attitudes toward injury are important. Where injury deaths are cul-
turally viewed as determined by fate, there will not be a receptive response to
an injury control initiative. Many cultures glorify risk-taking behavior involving
dangerous acts of physical ability. Risky behavior is often considered brave or ad-
venturesome in contrast to cautious behavior which may be seen as cowardly or
dull. These have positive and negative connotations. Children raised with access
to television are exposed to these cultural values from a very young age by char-
acters who engage in exciting, risk-taking behaviors without any connection to
real consequences.
Socioeconomic factors are also important to consider when addressing the
problem of mechanical hazards. Injury rates are linked with poverty within both
developed and developing nations. Much of the world's population lacks the re-
sources to provide optimal safety in their immediate environment. The necessity
of obtaining food for the family by riding a broken-down bicycle through
crowded, poorly maintained streets without a helmet is an example of this. Gov-
ernments and industry are tempted to compromise safety for economic reasons,
leading to tragedies such as the collapse of a public building. Many transporta-
tion accidents involving trains, ferries, and buses are the result of inadequate re-
sources provided for the safe upkeep and regulation of roads, rails, and vehicles.
Mechanical hazards cannot be considered in isolation from other hazards and
realities of day-to-day life. Perceived injury risks are mentally weighed against
other environmental hazards, necessities of survival, and perceived benefits of
accepting a risk. Consider the risk of sleeping in a poorly constructed shack that
would cillapse in an earthquake versus the risk of having no shelter at all; the
risk of traveling through an unsecured zone of conflict to obtain food versus the
risk of starving; and the risk of driving on a crowded freeway to work rather
than taking safer public transit for the benefit of saving time and preserving in-
dependence. In approaching any injury control issue, the cultural and socioeco-
nomic context must be appreciated.
Impact of Injury on the Individual and Society

Injury is a major cause of mortality throughout the world and has been described
as the most underrecognized major public health problem. For example, injury
is the single greatest killer of North Americans between the ages of 1 and 44; in
Canada, injuries are responsible for 63% of all deaths between the ages of 1 and
24 (Shah, 1994). A similar pattern exists in most developed countries. The un-
portance of injury is becoming increasingly recognized in developing countries,
as injury mortality is high in developing countries and generally decreases with
development. The only exception is traffic accident deaths, which increase in line
with the growth of motor vehicle use in a country. While traditional health prob-
lems of infectious diseases and malnutrition remain important causes of mortal-
ity in developing nations, increased urbanization and the influx of automobiles
(often on roads not designed for them) has led to increased mortality from in-
jury.
Surveillance systems for nonfatal injuries are relatively new and are subject
to underreporting. Thus accurate morbidity incidence data are difficult to obtain.
However, many local and national reporting systems are able to capture injuries

for which hospital care was required. Some surveys and cohort studies have been
done to obtain community estimates. It is estimated, for instance, that each year,
one out of three adults and children experience a nonfatal injury such that they
seek medical care or are unable to carry out their usual activities (NCIPC, 1989).
For every death of a child caused by injury it is estimated that 45 injuries re-
quire admission to hospital, 1270 are treated in an emergency room and are re-
leased, and likely twice that many do not require hospital care (Guyer and Gal-
lagher, 1985). Beyond the acute event, injuries contribute greatly to the morbidity
of long-term disability and chronic disease. Trauma is estimated to he responsi-
ble for 78 million disabled individuals worldwide, which is 1 5% of the world's
disabled population (WHO, 1982). In the United States, one-quarter of perma-
nent disability results from trauma, and highway trauma alone is considered re-
sponsible for 20,000 new cases of epilepsy annually (Wallcr, 1986).
One way to describe the prematurity of death is the calculation of potential
years of life lost (PYLL). The age at which a death occurs is subtracted from a stan-
dard age (usually 65) and the difference is the number of premature or produc-
tive years of life that were lost because of the young death. For example, a traf-
fic fatality at age 20 results in 45 years of PYLL, whereas a similar death at age
60 only results in 5 PYLL. While this approach is not intended to judge the value
of a lost human life, this measure is used to describe the loss to the individual
and to society of the potential contributions an individual may have made. In-
juries account for an enormous amount of PYLL even in comparison to other
leading causes of death (cardiovascular disease and cancer) that tend to occur in
older age-groups. In the United States, the PYLL due to injury in 1985 was more
than cancer and cardiovascular diseases combined (NCIPC, 1989).
When calculating the cost of injury, one must take into consideration initial
rescue and transportation costs, medical care costs, rehabilitation ccsts, and the
cost of long-term support and lost productivity for those disabled. These costs are
far-reaching in addition to the cost of human suffering. The direct cost of all in-
juries occurring in the United States in 1985 was estimated at $45,000,000,000.
Lifetime cost per death for injuries was significantly greater than cancer and car-
diovascular lifetime costs combined in the United States (Kraus and Robertson,
1992). This largely reflects the early age of injury and long period of treatment,
support, and rehabilitation. Even minor injuries are costly, as injuries are the
leading cause of physician contact in some countries (WaIler, 1986). The impact
of injuries clearly reaches beyond injured individuals to families, employers,
health care systems, and communities.
Vulnerable Groups
Children, the elderly, and disadvantaged groups have higher rates of injury than
the overall population. Peak ages for fatal injuries are ages 1-4, 15-25, and over
70. Deaths in the 15-25 year range are mostly motor vehicle related. At all ages,
males have higher injury death rates than females.
The rates of child injury mortality have been falling in maiiy countries over
the last few decades; since 1960 injury mortality in boys aged 5-14 years has
fallen 60% in Australia, 53% in Canada, and 33% in the United States (Pless,
1994). However, these figures have not decreased at the same rate as deaths from

other causes. In 1930, deaths from diseases were eight times as common as deaths
from injuries in Canadian children aged 1-4 years. Disease and injury death rates
reached equivalence by 1980, as disease death rates had shown dramatic reduc-
tions while injury death rates had decreased by only half (Baker et al., 1984).
Currently, injury takes more lives of Canadian children than the next nine lead-
ing causes combined, including cancer, circulatory diseases, infectious diseases,
congenital anomalies, and diseases of the nervous and respiratory systems (Guyer
and Gallagher, 1985).
Elderly people are particularly vulnerable to injuries from falls. Elderly women
who fall are particularly subject to fractures due to osteoporosis (thinning bones).
Hip fractures cause more deaths and disability and are more cosily than all other
fractures due to osteoporosis. Hip fractures result in death in 10%-20% of vic-
tims, often not because of the intrinsic nature of the injury, but because of the
resulting sequelae. Falls are the leading cause of injury mortality in the elderly,
whereas falls are the leading cause of morbidity but not mortality at other ages.
Most falls occur among the elderly. Additionally, suicide rates are highest among
the elderly. Suicide will be discussed in Intentional Injury, below.
Disadvantaged groups have also been noted to have higher rates of injury, as
noted in Chapter 1. Minority groups are noted to have higher injury mortality
rates, which is thought to be related to income and living conditions. Poverty
has also been associated with increased rates of injury. This may be due to greater
exposure to environmental hazards, as poor, untrained, and undereducated peo-
ple may perform the most dangerous jobs and live in poorly maintained hous-
ing in urban areas with high rates of violence (Kraus and Robertson, 1992). Al-
cohol use is also associated with increased injury rates, and alcohol use is also
more prevalent in low-income populations.
Injury Settings
Historically, injuries that occur at work and injuries that occur in other settings
have been considered separately, more for practical reasons than for conceptual
reasons. Work environments often present a high level of exposure to mechan-
ical hazards both in terms of the magnitude of risk (working with dangerous ma-
chinery) and the length of exposure (40 hr a week for 30 years). Legislation has
been passed in many jurisdictions to control and regulate the workplace for the
protection of workers, as discussed further in Chapter 10. In some jurisdictions,
compensation systems exist to cover the financial burden of injury on the worker
through payment generally charged back, at least partially, to the employer where
the injury occurred. The cost of workers' compensation to employers has added
further incentive to explore preventive options. The emphasis on injury preven-
tion has also contributed to the training of physicians, nurses, ergonomists, and
other professionals with expertise in the prevention and treatment of work-
related injuries. The work and research of these professionals have greatly ad-
vanced the understanding of injuries in the workplace.
In contrast, injuries that occur elsewhere, such as in the home, on the road,
and in various places of recreation, have not received an equal amount of at-
tention. The situations in which injuries occur are diverse, and no one health
professional or body has been charged with the overall responsibility of com-

munity injury prevention. Additionally, safety regulation of the general com-
munity, such as seat belt legislation, sometimes runs into opposition on the
grounds of civil liberty infringement. As a result, community injury prevention
is a relatively new field that began in the 1960s and has made rapid advances
since the 1980s. Currently, there is a network of communities around the wcrld,
sponsored by the WHO, that is devoted to reducing trauma from all causes. The
participating communities in this Safe Community Network have developed
strategies for making activities of daily life safer in road traffic, at work, recre-
ation, and school yard play, and in sports, travel, and household activities.
Conceptually, there is a great deal of ovcrlap between workplace injuries and
other injuries. Someone using a power tool at work or a power tool at home is
exposed to the same biomechanical hazard. Even more striking is the family farm
where the workplace and home are one and the same. Since this traditional dis-
tinction still exists, further discussion of specific types of injury will be organized
around the setting in which injuries occur. The one departure from this is in-
tentional injury, which can occur in any setting. Intentional injury includes as-
sault and suicide (violence), as opposed to most other injuries, which are non-
intentional. Some countermeasures have been effective in reducing both
intentional and nonintentional injuries. For example, high fences on the roofs
of tall buildings prevent nonintentional falls, suicides, and homicides.
Occupational Injuries and Ergonomics
Occupational injuries represent a serious cost to industry and to society, and they
tend to affect people during their most productive years, when they have fami-
lies to support. Injury at the workplace results in significant working time loss,
disability, and fatalities. As mentioned earlier, the mechanism of injury does not
differ from that of injuries sustained elsewhere, but the exposure may be great
in some worksites. Forestry, construction, mining, and fishing are occupations
with high rates of work-related trauma. Agricultural injuries are often very se-
vere, occur in rural locations where medical care may not be easily accessible,
and may affect family members, including children, who are working and living
on the farm. Ironically, healthcare is another sector in which injury rates are
high. Back injuries are the most common type of work-related injury. Muscu-
loskeletal injuries account for the vast majority of time loss claims for workers'
compensation. Injuries that result from cumulative trauma, kncwn also as repeti-
tive strain injuries, arc particularly costly (Yassi, 1997; Yassi, 2000).
As industrialization develops in a country, new and serious work-related me-
chanical hazards emerge. The tragic experience of many injured workers has
caused the most enlightened industries to develop and apply effective safety mea-
sures to protect workers against injury from moving parts of machinery, heavy
falling objects, and slippery or uneven floors (including obstructions on the floor)
(see NIOSH, 1995 and ILO, 1998). Nonetheless, millions of workers will lose their
limbs and lives in future years because of lack of awareness of and interest in
their safety at many worksites and because industrial/factory safety norms are
not in place.
The elements of a work-related incident can he viewed using the host—agent-
environment triangle, which includes the person susceptible to injury (the host), the

hazard that is capable of inducing the injury (the agent), and an environment where
both coincide in the workplace. Together these elements create a situation that is
the context for the incident. A person may decide whether to take a risk on the
spur of the moment and may not perceive the hazard, giving it faulty appraisal.
This person may be distracted, not trained to recognize the hazard, or make a de-
cision that in retrospect was not reasonable. There is a very critical period just be-
fore the incident when these factors come together into a particular incident-pre-
disposing situation. Most of these situations will develop into a near-miss—an injury
that could have happened but does not occur. But there is a certain probability
that these elements will come together and the injury will occur.
In theory, at least, there are factors common to each type of injury that can
be modified. Proper equipment must he purchased, with care given to the phys-
ical layout of the worksite to ensure appropriateness. Workers must be trained
to recognize the hazard and to use safety equipment properly. Policies and pro-
cedures must be developed to empower workers to use proper techniques, with
the consequences of not doing SO also specified. The workplace culture must fos-
ter senior management commitment and full worker participation to ensure that
the policies and procedures are feasible and will he enforced. Ergonomics is most
commonly discussed within the context of the workplace environment, although
it can be applied to the wider environment. The prevention of injuries is one ma-
jor objective of the practice of ergonomics, as are good workplace design and in-
creased efficiency. Ergonomics is devoted to designing a workplace that can be
modified and adapted to the needs of individual workers. Whenever possible, it
is preferable to change the environment rather than to find a worker with spe-
cific characteristics to do the job. Tasks requiring upper body strength to pull
levers may he redesigned for women by using foot pedals, for example. Changes
in the workplace environment will be more reliable, protect a greater number of
workers, and he more conducive to a healthy and productive work environment
than measures which rely on changing the behavior of workers or selecting cer-
tain workers for distinct tasks.
Information processing is made much easier and more accurate when pre-
sented to the senses in a way that facilitates rapid perception and cognitive in-
terpretation. Instruments can he clustered and designed such that deviations from
the expected are immediately obvious. The selection of type fonts, colors, cod-
ing schemes, visual cues, and labels is an inexpensive but highly effective way
to increase efficiency and reduce errors in performing complex tasks. Likewise,
readouts can be designed so that unusual or urgent information is easily and
rapidly visible by color-coding or by visual displays, rather than being presented
on a meter. Additionally, the application of ergonomic principles makes it pos-
sible, usually at low cost, to accommodate the needs of disabled or recuperating
workers and to ensure their continued employability.
Traffic-Related Injuries
Motor vehicle–related crashes are by far the leading cause of serious injuries in
most countries. Unfortunately, high rates of injuries are usually tolerated by so-
ciety and accepted as an unavoidable cost of transportation. This is quite unnec-
essary as injuries can be prevented by improved design of roads, improved de-

sign and regular maintenance of cars and trucks, education of drivers, and en-
forcement of traffic rules.
The annual number of traffic deaths globally is estimated to be 500,000 and
is increasing. Of these, 350,000 occur in developing countries (WHO, 1992a).
While these developing countries have lower rates of vehicles per population, this
is offset by a higher rate of fatality per vehicle and a high proportion of motor-
cycles, which are particularly hazardous compared to cars. The anticipated growth
of motorcars in developing countries and newly independent states in the com-
ing decades creates a real challenge for public health. If effective preventive mea-
sures against crashes and injuries are not taken, traffic injuries could become one
of the most severe epidemics. As discussed previously, the cost of traffic injuries
is staggering. In developing countries motor vehicle crashes are estimated to cost
between 1% and 2% of gross national product (GNP) (WHO, 1992a).
The highest rates of traffic fatalities occur among young adults, and among
males more than females. Traffic injury is also a leading cause of hospitalization
in people under 45. It is estimated that globally 30 million people are disabled
as a result of traffic injuries. This accounts for 5.8% of all disability and 38% of
all disability from trauma (WHO, 1982). Alcohol use is involved in a high pro-
portion of fatal crashes. Heavy drinkers are 4.4 to 5 times more likely to have a
motor vehicle crash than the general population.
Traffic mortality and injury rates have declined in developed nations. This
trend has paralleled safety initiatives such as improved roads, driver education,
seat belt legislation, infant car restraints, and improved vehicle design. There is
much work yet to be done to fully apply known technologies (e.g., optimum ve-
hicle design, including airbags, and crash-friendly roadways) and to develop fur-
ther technologies and strategies to combat this important public health problem.
Bicycle injuries are also very common worldwide. Although bicycle helmets
are thought to prevent 85% of head injuries and 88% of brain injuries, the use
of helmets is still low. Some Canadian provinces and other countries (e.g., Ger-
many, Sweden, and New Zealand) have passed mandatory helmet laws, either
for the whole population or for children.
Home- and Recreation-Related Injuries
Home- and recreation-related injuries cover a broad range of settings and types
of injury. Home-related injuries affect primarily children and the elderly and can
be very serious. Other than work, the home is the most common place for fatal
injuries. Recreation- and sports-related injuries tend to affect primarily young
people. Although these injuries tend to be less serious in general, they are often
troublesome, costly to treat, and may occasionally be fatal. They are also a com-
mon cause of lost time from work.
Drownings, burns, poisoning, and falls are critical causes of pediatric morbid-
ity and mortality. Young children can drown in only a few centimeters of water
in a matter of seconds and should never be left unattended near water or in the
bath. Backyard poois and natural open water are hazards for young children who
may wander unattended into the water. Pools should have adequate fencing and
locks to protect against this hazard. Young children may be the victims of fire as
often they are not able to remove themselves from a burning building. Properly

functioning smoke detectors are effective in alerting a family in time to remove
children from a burning home. Innovative programs supplying smoke detectors
to families of newborns at hospital discharge have been implemented in an at-
tempt to make this countermeasure more widely adopted. Smoking is related to
many deaths—either parents' cigarettes cause the fire or matches and lighters are
within children's reach. Lighters are now required to be child resistant in some
countries. Regulations prohibiting flammable sleepwear have also been adopted
by some countries, thus decreasing burn injuries. Hot water scalding is a major
cause of home burn injuries in young children and the elderly, who have more
vulnerable skin and are often not able to remove themselves quickly enough from
a situation of inadvertent exposure. Hot water tanks are often set at levels at which
scalding can readily occur. It is thus recommended that hot water tanks be pre-
set to prevent scalding, and families with young children be warned to he partic-
ularly vigilant in this regard. The practice of cooking over an open fire, common
in many areas of developing nations but also a practice in many poorer commu-
nities of the developed world, can result in serious burns in young children.
Inadvertent poisoning is a major cause of childhood morbidity and mortality.
Families with young children are advised to store medications and household
chemicals out of children's reach and lock cupboards as needed (an active strat-
egy). More effective measures have been passive ones, such as child-resistant pill
bottles and limits on the dispensing of children's analgesics to nonlethal amounts.
Choking, suffocation, and strangulation can be lethal in the home or recre-
ational environment. Foods associated with high risks of choking are peanuts, un-
sliced sausages or wieners, hard candy, and hard, crunchy food such as carrots.
Toys with small parts and plastic bags have caused inadvertent suffocation. Wa-
terbeds are also known to pose a suffocation hazard for young babies. Strangula-
tion deaths have resulted when loose clothing, necklaces, drawstrings, or skipping
ropes become entangled during play. Cribs are now regulated to avoid spaces be-
tween slats or the frame and the mattress that can permit strangulation.
Falls are a critical cause of pediatric injury. Serious and lethal falls from high-
rise windows have prompted some communities in the United States to apply win-
dow locks to all excessively high apartment dwellings, with good results. Baby walk-
ers were associated with particularly severe injuries when the walker inadvertently
fell down the stairs. Such walkers have been removed from many markets.
Many countries provide playgrounds for children in school and community
parks, and it has become increasingly recognized that the playground equipment
provided can be associated with a significant injury burden—mostly upper arm
fractures and head injuries. Many countries, including England, New Zealand, Aus-
tralia, Canada, and the United States, have developed guidelines over the past
decade to influence the safer design of playground equipment. Most injuries oc-
cur when children fall from excessive heights to hard ground. The combination of
decreasing the height and providing impact-absorbing material beneath the equip-
ment is an example of a passive environmental approach to an identified hazard.
Another area of concern involves the use of off-road vehicles, which are used
mainly for recreation but also in farming. All-terrain vehicles (ATV5) are known
to be particularly hazardous; injuries also occur with the use of dirt hikes, snow-
mobiles, dune buggies, and go-carts. Although these injuries mostly involve men

in their micl-20s, children and teenagers are also injured. The design of ATVs ren-
ders them unstable and results in many rollover injuries.
Intentional Injury
Intentional injury is a particularly difficult problem. War, civil unrest, homicide,
suicide, and assault all reflect deeply rooted social problems. Although they are
usually beyond the scope of the environmental health professional's duties, the
control of intentional violence is a fundamental problem combining human rights,
social development, international cooperation, peacekeeping, and law enforcement.
Intentional injury can be directed toward oneself (suicide) or toward others
(murder, assault and child abuse). Suicide represents a significant proportion of
PYLL. Even though most suicides occur among people below the age of 40, the
highest rates of suicide in individual demographic groups occur in the elderly,
and particularly among elderly men. Suicide rates have remained stable for most
age-groups but are rising among teenagers and young adults. Disadvantaged mi-
norities also experience higher rates of suicide. In general, although females make
more suicide attempts, males are more successful in their attempts and so have
a higher suicide mortality rate. Firearms, hangings, and poisonings by gas (e.g.,
carbon monoxide) or medication overdose are the most common means used to
accomplish suicide in most developed countries.
Assault is particularly prevalent in crowded urban areas where criminal ac-
tivity is widespread. Youth gang violence in association with illicit drug activity
is increasing in many countries and many young lives have been tragically lost.
The availability of guns in a society is predictive of the lethality of crimes and of
domestic violence. Unintentional shooting injuries also increase with the avail-
ability of firearms, and the victims are often children.
Child abuse is a particularly tragic form of violence. Often the social disrup-
tions of unemployment, alcohol or drug abuse, or mental illness are taken out
on the most vulnerable. Scalding, cigarette and other burns, drownings, blows,
tight grips, and violent shaking are typical intentional injuries. Sexual abuse of
children is becoming increasingly recognized and is known to be underreported.
Often disclosure occurs much later in adult life once tremendous damage and
suffering have occurred.
In some areas of the world experiencing war and conflict, violence is an all
too familiar part of life. Recent tragedies in Rwanda, Bosnia, Sierra Leone, Liberia
and Kosovo painfully illustrate the toll of conflict. Land mines continue to maim
countless innocent people. Massive loss of life and injuries from terrorist attacks
represent another much-feared aspect of political violence. Environmental health
professionals need to appreciate the necessity of peace as a prerequisite to health
(see Chapter 11, Health Consequences of War).
Concepts in Injury Prevention

To approach any of the injury problems mentioned above, it is necessary to un-
derstand a few key concepts in injury prevention. One such concept is the dis-
tinction between active and passive approaches to injury control. The distinction
lies in the level of effort or action required on the part of individuals for the strat-
egy to be effective. Active strategies are those requiring initiative (such as seat be

TABLE 2.9
THE HADDON MATRIX APPLIED TO MOTOR VEHICLE-RELATED INJURIES
Factors
Phases Human Vehicle Environment
Preinjury Prevent drunk driving Ensure braking capacity Ensure visibility of hazards
Injury Use seat belt Avoid sharp or pointed Provide barriers that
surfaces prevent head-on crashes
Postinjury Prevent hemorrhage Maximize rapidity of Facilitate emergency
energy reduction medical response
5iirci Haddon, 1980
use) whereas passive strategies lie at the opposite end of the continuum—little or
no action is required (such as automobile airhags). The consensus within the in-
jury prevention field is that passive strategies should he employed wherever avail-
able, and when active strategies are necessary, they are most effective when man-
dated. The need for a flexible combination of strategies has been recognized.
Another key tool in injury prevention is the Haddon matrix, which is based on
the concept that injury events can be broken down into preinjury, injury, and postin-
jury phases. This phase concept is combined with the traditional causation concepts
of host, agent, and environment, resulting in a way of breaking down an injury sit-
uation and thinking about possible points of intervention. This matrix approach has
been embraced by injury prevention researchers and applied in various forms to
numerous injury prevention situations. An example of how this can be used is
shown in Table 2.9, where Haddon's matrix is applied to analysis of motor vehicle
injuries. It is generally accepted that control programs that modify the vehicles, vec-
tors, or environment are more effective than those that modify the host.
A further contribution to injury prevention analysis is Haddon's ten coun-
termeasure strategies for reducing injuries. These are generic measures that can
be applied to any type of injury prevention initiative, including the physical haz-
ards discussed previously. These are listed in Table 2.10 in abbreviated form.
Safety measures should he integrated into a comprehensive package so that
they are mutually reinforcing, hacked by public policy, specific to local hazards,
TABlE 2 10
HADDON'S TEN COUNTERMEASURE STRATEGIES FOR REDUCING INJURIES
Injury Reduction Strategy
Prevent the creation of the hazard in the lirsi place.
Reduce the am()utit of hazard brought into being.
Prevent the release of an existing hazard,
Modify the rate or spatial distribution of release of the hazard from its source.
Separate, in time or in space, the hazard and that which is to be protected.
Separate the hazard and that which is to be protected by interposition of a material harrier.
Modify the basic qualities of the hazard.
Make that which is to he protected more resistant to damage from the hazard.
Counter damage already done by the environmental hazard.
Stabilize, repair, and provide rehabilitative and cosmetic surgery.
Source: Haddoii, 1980.

clear and explicit, and aimed toward realistic, obtainable objectives that every-
one understands. Project coordinators should be able to evaluate progress.
PSYCHOSOCIAL HAZARDS
Psychosocial Hazards and Stressors

Uncertainty, anxiety, and a lack of a feeling of control over one's OWfl life situ-
ation or environment lead to what is popularly called stress. The word stress is
sometimes used to describe a stimulus: a specific event or situation that causes
a mental or physiological reaction. To keep the terminology straight, it is best to
speak of stressors rather than stress in this meaning. Stress can thus be defined as
a human response to stressors. This definition of stress indicates the state of pres-
sure that a person experiences. Another definition emphasizes the fact that stress
is a process, resulting from the interaction between humans and the environ-
ment. The stress process consists of two stages: the first involves deciding whether
an event (stressor) indeed poses a hazard; the second involves appraising the pos-
sibilities of dealing with the situation. As long as an individual can cope with the
stressors, there is no problem. However, when coping strategies are no longer
adequate, adverse stress reactions will occur.
For many people in both developed and developing countries, stress is a part
of daily life, and it may lead to a variety of serious health effects, including de-
pression, suicide, substance abuse, violence against others, psychosomatic dis-
eases, and general malaise. Psychosocial hazards are those that create a social en-
vironment of uncertainty, anxiety, and lack of control. This may include the
anxiety about mere survival from violence, as in the case of war-torn countries,
or the uncertainty about future health effects of radiation exposure, for exam-
ple, after the Chernobyl accident.
The occupational environment is another setting in which health can be dam-
aged by a high mental burden. The well-known Karasek model is used to docu-
ment how jobs with a low degree of decision-making authority (low control) and
a high degree of physical or mental demands are particularly stressful. The in-
creasing demands on workers and office staff as companies go through restruc-
turing for increased efficiency (meaning fewer employees having to produce
more) are a major psychosocial hazard. Women are generally exposed to addi-
tional stressors as they often must try to strike a balance between their roles as
employee and homemaker. Five categories of potential sources of work-related
psychosocial stress can be distinguished: factors intrinsic to the job, the role of
the worker in the organization, career development, interpersonal relationships
at work, and organizational structure and climate (Kalimo Ct al., 1987; Chapter
10 will also address this further). The major determinants of health at work are
indeed those workplace organizational factors that determine psychosocial well-
being of workers (Polanyi et al., 2000; Sullivan ci al., 2000). In the private so-
cial environment, the death of a close friend or family member, divorce, or other
family-related events can also be seen as psychosocial hazards.
The urban environment has its own characteristic psychosocial hazards. Poor
or nonexistant urban planning, overcrowded residential areas, lack of sufficient

recreational areas, disrupted social structures, and sucial isolation are some of the
major examples (Chapter 7 will address these further). The exact impact of each
individual hazard is difficult to establish, however, since a mixture of urban stres-
sors and socioeconomic factors is usually involved. Finally, potential environ-
mental health hazards of any kind (waste incinerators, emissions from chemical
industry, or natural disasters) may induce psychological stress responses.
Health Effects of Stress

The modern perception of stress is that it is a negative or adverse reaction. The
evolutionary perspective is different, in that stress is considered to he an impor-
tant mechanism to prepare the human organism for urgent action, both physi-
cally and mentally. The physiological characteristics of the stress reaction include
increases in heart rate, blood pressure, respiration, and blood transport to skele-
tal muscles and a simultaneous decrease in digestive activity. Increased produc-
tion of stress hormones, such as epinephrine and cortisol, also play an important
role in this reaction. All of these reactions prepare the individual for defensive
actions—attack or flight. They thus improve the individual's chance of survival
and can influence the success of a given species.
If an individual is continuously exposed to environmental stressors and has no
adequate coping strategies, adverse health effects are a likely outcome. Cardiovas-
cular diseases such as arterial hypertension and ischemic heart disease may be as-
sociated with stress. Other medical conditions such as peptic ulcer disease, bronchial
asthma, and rhetimatoid arthritis are influenced by psychological factors, although
the prevalence of these diseases is less than that of cardiovascular diseases.
Since cardiovascular and other stress-related diseases take many years to be-
come clinically significant, there is an opportunity to prevent these diseases at
an early stage. This requires methodologies to quantify environmental or occu-
pational stress. Since psychological factors are more difficult to measure than
physical factors and may vary substantially among individuals, attempts have
been made to identify physiological stress indicators. Useful screening measure-
ments may include the ratio of epinephrine to norepinephrine in urine or blood,
the ratio of potassium to sodium in urine, or levels of lipoproteins (cholesterol
and triglyceride) in blood. As an example, it has been demonstrated that mdi-
viduals living near the nuclear power station at Three Mile Island, where an ac-
cident was narrowly averted in 1979, had higher urinary levels of epinephrine
and norepinephrine 1 year after the event than controls living further away. It
should be realized, however, that all individuals may react differently to envi-
ronmental stressors and that many other variables of personality, experience, and
mood may influence the measured stress indicators. Results of these studies
should therefore be interpreted with caution.
alld 1nfl c
Give examples of reproductive effects caused by each of the following: a chem-

ical, a physical agent, a biological agent, a mechanical hazard, and a psychoso-
cial hazard. What type of evidence led you to the conclusion that each of the
hazards you cited causes the effect in question.

3
RISK ASSESSMENT
LEARNING OBJECTIVES
After studying this chapter, you will be able to do the following:

• define the elements of risk assessment
• describe the types of information needed for each element of risk assess-
ment
• describe how hazards can be identified in the field
• describe extrapolation methods used for the assessment of human dose-
response relationships
• explain the difference between threshold and non-threshold effects, and to
indicate the importance of this difference in risk assessment
• discriminate between different types of markers of exposure and provide
several examples of useful markers of exposure
• describe how estimates of the magnitude of the potential risk are made,
including the assessment of exposure
• describe the application of toxicology to the assessment of human health risks
• illustrate the difference between direct and indirect approaches of exposure
assessment
• describe potential errors in environmental sampling
CHAPTER CONTENTS
The Health Risk Assessment and Risk Relationship Between Dose and Health
Management Framework Outcome
Epidemiological Methods Dose—Effect and Dose—Response
Steps in Epidemiological Field Relationships
Investigations Calculating Risks for Threshold
Study Methods Effects
Quantifying Risks Thresholds and Other Important
Study Difficulties and the Benchmarks
Determinates of Causation Uncertainty Factors in Establishing
Cluster Investigations and Thresholds
Ecological Studies Calculating Risks for
Non-Threshold Effects
Hazard Identification in the Field
Occupational Environment Human Exposure Assessment
General Environment Options in Approach
104
Personal Exposure Monitoring Errors and Quality Assurance
Biological Monitoring of Exposure Ensuring Adequate Sample Size
or Effect Health Risk Characterization
Indirect Approaches to Estimation General Approach
ol Exposure Specific Health Risk Assessments
Estimating Inhalation Exposure in Field Situations
Estimating Ingestion Exposure
Health in Environmental Impact
Estimating Skin Exposure and
Assessment
Doses
Principles of Population Sampling
THE HEALTH RISK ASSESSMENT AND RISK

MANAGEMENT FRAMEWORK
The ultimate goal of studying the relationship between environmental hazards
and health is to take some action to reduce or eliminate those hazards or to re-
duce the harm that may result from their effects. This is called risk management.
But before anything can be done, the risks themselves must be identified and
thoroughly characterized. This process of analysing the possible effects on peo-
ple of exposure to substances and other potential hazards, such as radiation, is
known as a form of risk assessment. The steps typically taken in this process are
shown in Figure 3.1. Because of different laws and approaches to regulation in
different countries and different institutions, the terminology used in various re-
ports on risk assessment varies, even in the same countries. The one used here
is commonly found in WHO, ILO, and UNEP documents.
The first step in risk assessment is to identify hazards based on results from the
relevant toxicological and epidemiological studies. This hazard identification step
may also involve describing how a substance behaves in the body, including its in-
teractions at the organ, cellular, and molecular levels. Such studies may also iden-
tify toxic effects that are likely to occur under experimental conditions. Hazard iden-
tification may be considered a qualitative description of potential health effects. Some
of the research methods used to identify environmental hazards (e.g., toxicological
tests) were introduced in Chapter 2. In the section Epidemiological Methods we will
deal with epidemiological methods to identify hazards, and in the section Hazard
Identification in the Field will discuss how hazards are identified in field studies.
In the next step of risk assessment, research data have to be used to describe
and quantify the relationship between exposure or absorbed dose and its related
health risk. This second step is known as a dose—response assessment. It is vital that
the methods used to extrapolate data (e.g., from high to low exposure levels,
from animal studies to humans, or from short-term to chronic exposure) are ap-
propriate. The dose—response assessment should describe and justify the meth-
ods of extrapolation used. It should also describe the statistical and biological un-
certainties of these methods. The dose-response relationship will be discussed
further in the section Relationship Between Dose and Health Outcome.
The third step, called exposure assessment, is to measure the exposure itself,
identifying the sources of exposure, estimating intake into the body by the
various routes, and obtaining demographic information to define the exposed
population. Field measurement data provided by monitoring and surveillance sys-
RISK ASSESSMENT 105

Research Risk Assessment
Laboratory and field observations 1. Hazard Identification

(including epidemiological studies) of (Which are the health effects
adverse health effects from exposure to that this agent can cause?)
particular agents.
Quantitattve dose-response studtes and 2. Dose-Response Assessment 4. Risk Characterization

extrapolation from high to low dose (What is the relationship (What is estimated occurrence of the adverse
and from antmals to humans. between dose and occurrence effect in a given population?)
of health effects in humans?)
Field measurements estimating 3. Exposure Assessment 5. Risk Management

exposures in defined populations. (What exposures are currently (Development, evaluation and implementation of
experienced or antictpated under regulatory options, aimed at risk reduction and
different conditions?) control)
Figure 3.1 Steps in risk assessment.
tems are obtained, when possible, to assess the environmental quality. If no mea-
surement data are available, emissions may be calculated or estimated at the
source and exposure levels may be estimated on the basis of mathematical mod-
els showing how these emissions are carried by air, water, or in the ground. In-
tegration of these data provides an estimation of the most likely exposure levels
for individuals who may come into contact with the contaminants. This part of
the risk assessment process is addressed in greater detail in the section Human
Exposure Assessment.
Risk characterization is the integration of the first three steps in the risk as-
sessment process. Ideally, it should produce a quantitative estimate of the risk in
the exposed population, or estimates of the potential risk under different plau-
sible exposure scenarios. Typically, a range of estimates is developed, using dif-
ferent assumptions and statistical methods that determine how sensitive the es-
timates are to basic assumptions in the model. If diffetcnt health effects arc likely
to occur, the risk of each should be characterized. Other exposures or factors con-
tributing to the health effects should also be characterized. This process will be
described in the section Health Risk Characterization.
The literature on environmental health risk assessment can be confusing, as
the same terms are used to refer to both generic risk assessments (often regula-
tory agency—based) and specific field risk assessments. Generic risk assessments
characterize a hazard in general scientific terms on the basis of anticipated ex-
posures and hypothetical population characteristics. However, when there is sus-
picion of a risk in a specific situation, it must be ascertained if people really are
sufficiently exposed for health effects to occur.
Risk assessment has its limitations. In practice, crucial data are frequently lack-
ing, and reasonable assumptions are made to arrive at a quantitative risk esti-
mation. Most risk assessments contain one or more of the many sources of un-
certainties that may accompany a risk assessment, listed in Table 3.1, and it is
essential to evaluate their impact on the assessment. This process, usually re-
ferred to as sensitivity analysis, may be quite complex.
In many situations, only a qualitative risk assessment may be appropriate. In
this approach, reasoned judgment is used, taking into account what information

TABLE 3.1
SOURCES OF UNCERTAINTY IN A RISK ASSESSMENT
Use of an experimental study involving an inappropriate route of exposure
Differences in biokinetics and/or mechanism of toxicity between species
Poor specification of exposure in experimental study, i.e., concentration, duration, route, chemical
species
Extrapolation of high-dose to low-dose situations
Difference in age at first exposure or lifestyle factors between experimental data and a risk group
Exposure to multiple hazards in epidemiology studies
Potential confounding factors
Misclassification of the health outcome of concern
Adapted 1mm I-ia llenbeck, 1993, with pe rinission -
is known. When there is little likelihood that an exposure could be harmful, a

qualitative risk assessment may he all that is necessary. If it is possible that a se-
rious adverse effect may occur and that people may be affected, a quantitative
risk assessment is usually preferred.
When the health risk of a specific environmental hazard or situation has been
characterized, decisions must he made regarding which of the various control ac-
tions should be taken. Regulatory agencies may develop regulatory options, eval-
uate the (public health, economic, social, and political) consequences of the pro-
posed options, and/or they may implement agency decisions. These actions and
decisions form the core of the risk management process, discussed in Chapter 4.
EPIDEMIOEOGICAL METHODS
Data from epidemiological studies may be used directly to identify hazards and
dose—response relationships. The types of studies used in epidemiology each have
their own benefits and limitations.
Steps in Epidemiological Field Investigations

A framework of epiderniological concepts and techniques through which envi-
ronmental health investigations may be carried out is presented in Figure 3.2. A
methodical program of research to control a particular disease or health problem
might follow the sequence described in Figure 3.2. Efforts to reduce mortality
and ultimately prevent diarrhea in children have followed this framework. In the
beginning, it is essential to define a case, identify the population at risk, and ob-
tain a measure of the excess risk. The first phase involves descriptive studies, which
are conducted to describe the current problem, e.g., how many children have di-
arrhea and to what extent it affects their health. These are followed by analyti-
cal studies to gain further information on possible causal factors, intervention stud-
ies (to evaluate possible treatments or prevention approaches), and development
of surveillance. The aim of analytical studies is to determine if any environmen-
tal factors (or other risk factors) are indeed associated with the problem (or out-
come of interest). Alternatively, enough data may exist to warrant implement-
ing controls. The follow-up then would be to determine if control of the suspected
environmental hazard would reduce morbidity or mortality. An ongoing sur -
RISK ASSESSMENT 107

DESCRIPTIVE ANALYTICAL INTERVENTION
EPIDEMIOLOGY EPIDEMIOLOGY EPIDEMIOLOGY
Define illness State hypotheses to Remove or modify
test the suspected cause
Consider hypotheses of the disease
and biological Choose study problem and study
significance approach: disease reduction
• cohort, or
Define population • case control
at risk
Design study: FURTHER STUDIES
Measure disease • sample size
excess • information on Advisory working
illness, details of group
Establish surveillance exposures,
confounding Collaborating agencies
variables
• ethics
• resources
• quality control NO ACTION
INDICATED
Perform study and
analyse results No significant disease
excess documented
Figure 3.2 Logical development of epidemiological field investigations. From WHO, 1991 a,
with permission.
vcillance program may be required to monitor progress and identify changes in

the pattern of the disease outcomes or causes.
Study Methods
Epidemiological study types differ considerably in their strengths and weaknesses.
Table 3.2 summarizes the main features of the traditional types of epidemiolog-
ical studies. Note that in each of these types of studies, the individual person is
the unit of analysis. Ecological studies, in which the community or region is the
unit of analysis, will be discussed later.
Descriptive studies may be longitudinal (often) or cross-sectional. Historical
studies provide trends over time in an exposure or in the health effects of inter-
est. Cross-sectional descriptive studies provide a snapshot of the exposure or the
effects at a given time, or both. Researchers conducting descriptive studies do not
try to draw associations between an environmental exposure and a health prob-
lem; instead, they simply try to describe the ways things have been or currently
are. However, both historical and cross-sectional studies can compare an expo-
sure or an environmental exposure prevalence to a health problem's prevalence
in a study group and a control group, to establish whether a link may exist be-
tween a risk factor and an outcome. The study designs used most often in ana-
lytical epidemiology are cohort studies and case—control studies. These two study
designs differ fundamentally from each other because they approach the ques-
tions of causation (or more precisely, association) from opposite ends of the cause-

V
.- --
- Vd V -
-
u c
Cl) C
Z
z
VV
H V V
Cl)
I iHh11
75
II
-C :-
V V
V
- C
CV
H U U
z
2 C) CC
C
z
ZJ
U U U IC U
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— - C
QC > > - > V
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0
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TIME
direction of inquiry
•*. disease
People Exposed
without disease
ation... disease
the
disease
Not exposed__f...*.Iro_disease
Figure 3.3 Design of a cohort study. From Beaglehole ci al., 1993, with permission.
and-effect spectrum. Cohort studies start with a population that has been exposed
to the risk factor, then the frequencies of disease in the exposed and unexposed
populations are compared as they occur over time (see Fig. 3.3). ('ase-control stud-
ies start with people who have the disease, then frequencies of exposure that oc-
curred in the past in the population with the disease and the population with-
out the disease are compared (see Fig. 3.4). Researchers using analytical
epidemiology must look out for bias in the information, or confounders, factors
that are not causal but may be associated with the exposure and the disease for
other reasons.
Case-control studies can provide powerful and accurate estimates of risk ra-
tios and are usually economical in terms of both cost and study duration. An ex-
ample of the use of a case-control study in testing the association between an
acute epidemic disease and a particular exposure is the toxic food oil syndrome
investigation that took place in Spain (see Box 3.1). Case-control studies can also
be used in examining chronic, long-latency, hyperendemic problems and are es-
pecially useful in studying rare diseases, as noted in Table 3.2.
Cohort studies have the advantage of being able to directly measure the risk
of a disease and calculate the actual population illness rate, the occurrence of ill-
TIME
direction of inquiry
..
Start with:
exposure f.*.-.- : cases

(people with
no exposure disease)
L Population
exposure
_k .... .. I controls
(people without
no exposure ... disease)
Figure 3.4 Design of a case-control study. From Beaglehole et al., 1993, with permission.

BOX 3.1
Toxic Oil Syndrome in Spain
In May 1981, a previously unknown disease appeared in Madrid, Spain. It subse-

quently spread rapidly to the provinces northwest of the city. Symptoms of the dis-
ease included respiratory distress, fever, rashes, nausea, and vomiting. Over 20,000
people were affected, and over 340 deaths occurred.
Many potential causes of the syndrome were investigated. Initial descriptive stud-
ies implicated a black market cooking oil as a possible cause for the syndrome. In a
subsequent case—control study, food ingestion histories of 124 people with the syn-
drome (the cases) were compared with 124 people without the syndrome (the con-
trols). Both groups were from similar socioeconomic backgrounds. One hundred
percent of people with the syndrome had reported consumption of the illegally mar-
keted cooking oil, but only 6.4% of the control group (those who were not sick)
had consumed the clandestine oil (as it was called in Spain).
Cases (with syndrome) ' l00% had consumed the oil

0% had not consumed the oil
Controls (without syndrome) > 6.4 1 Y. had consumed the oil
93.6% had not consumed the oil
In a similar fashion, within case families, the estimated amount of oil consumed per
person correlated with the severity of the symptoms of the disease. The syndrome
became known as toxic oil syndrome (TOS) and was probably caused by imidazoline-
thiol components, derivatives of isothiocyanate.
This is an example of a case—control study, as investigators started with indi-
viduals with and without the disease, and looked for an association to exposure be-
fore the symptoms started, in this case, ingestion of the cooking oil. Case—control
studies can he used in this manner to investigate the cause of an unknown disease
epidemic. If there is a statistically higher level of exposure in the cases than in the
controls, then the exposure may be the causative agent. (In this situation, with 100%
of cases having consumed the oil, and O% of cases not having consumed it, the odds
ratio, as discussed in the section Quantifying Risks, would be infinity.)
Within 2 months of the date when the initial case was recorded, the number of
persons contracting the syndrome had reached its peak and the incidence declined.
This decline corresponded with public education about the oil and the replacement
of the oil with uncontaminated cooking oil.
Source: WHO. 1990c.
ness in a defined population over a period of time is measured. However, cohort

studies can be costly, especially if the disease under study is rare. Large popula-
tion groups may be needed to achieve statistically meaningful results. Cohort
studies allow for the assessment of many competing risk factors, thereby pro-
viding a distinct advantage over case—control studies. Cohort studies are often
used to study occupational diseases, an example of which is provided in Box 3.2.
A prospective cohort study is one that starts with a group currently exposed to
a potential hazard or risk factor and an unexposed group. The groups are then
RISK ASSESSMENT 111

BOX 3.2
Vinyl Chloride and Cancer: An Example of the Historical
Cohort Study
The vinyl chloride monomer (VCM) is a gas produced largely through chlorination
of ethylene, a product of the petroleum industry. When polymerized, it forms
polyvinyl chloride (PVC), one of the major polymer plastics widely used today. It
has been produced commercially since the 1930s and its production has steadily in-
creased. It is widely used in floor tiles, seat covers, toys, water pipes, and other com-
mon products. Once considered a relatively inert gas, VCM was widely used for a
time as a propellant in spray cans.
In 1967, the U.S. National Institute for Occupational Safety and Health (NIOSH)
was notified that 4 cases of a rare liver cancer, angiosarcoma of the liver (ASL), had
occurred in a workforce of only 500 workers. Shortly thereafter, further observa-
tions were reported, including an Italian study on rats, that supported the associa-
tion between VCM and the development of ASL. The NIOSH decided to conduct a
historical cohort mortality study of workers at PVC polymerization plants to com-
pare observed cause-specific mortality rates among these workers with that expected
in the U.S. population. Four plants were selected for the study based on length of
operation, accessibility of records, and probable ease of follow-up. The total person-
years at risk for disease were calculated. Follow-up was virtually complete (1287
out of 1294 workers) with 10-year latency. Thirty-five cases of cancer had occurred.
Expected numbers of deaths were calculated according to the ages of the people at
risk. From the expected number of deaths in this workforce by age category and
the standardized mortality ratio (SMR) (for the workers with 10-year latency), it
can be seen that the cancer mortality is significantly increased. As the numbers are
small, only the excess in liver tumors is statistically significant. Excess numbers for
leukemia and lung and brain cancer should be noted as deserving further study.
95 016 confidence
Cause of death Observed Expected SMR intervals
Cardiovascular 57 54.7 104 79-135
Cancer 35 23.5 149* 104-207
Pulmonary 12 7.7 156 80-272
Liver/hiliary 7 0.6 1 167** 467-2404
Leukemia/Iyinphoma 4 2.5 160 51-386
Brain 3 0.9 333 85-907
Other 9 11.8 76 35-145
Cirrhosis of liver 2 4.0 50 8-165
Pulmonary disease 6 3.4 176 64-384
(excluding cancer)
Violent deaths 13 14.2 92 49-157
All other causes 22 26.5 85 52-126
Unknown cause
TOTAL 136 126.3 108 90-127
*p = 0.05; ** p = 0.01.
Source; Falk and Heath, 1986

compared to see who gets the disease and who does not over time. A historical
cohort study starts with information about who had been exposed to a potential
hazard and then determines their disease rates since the time of that exposure.
Both types of cohort studies start by defining an exposed population with the
goal of determining disease rates that follow.
Variants of cohort studies and case—control studies are proportional morbidity
studies and nested case—control studies. In the former, all deaths are classified ac-
cording to cause. The proportion of the study group dying of the cause of inter-
est (e.g., cancer) is compared to the proportion of an age-matched (standardized)
general population dying of this cause. This approach works well for uncommon
diseases but is subject to distortions then applied to conimon conditions such as
heart diseases. A nested case—control is the second phase of a cohort study. Here,
the causes of the disease in the exposed group are further investigated by com-
parison to controls.
Quantifying Risks
There are a few standard equations used in epidemiology to determine if the
study population is at an increased risk or has an increased number of cases of
the disease in question compared to a standard population. The rate of disease,
the most fundamental measure (Fig. 3.5), can he measured in terms of incidence
(new cases) or prevalence (existing cases). To determine if the observed rate is
excessive, a risk ratio, or relative risk should be calculated. These are usually cal-
culated from cohort studies.
A risk ratio of 1.0 means that the rate of the problem (or outcome of inter-
est) in the group being studied is not different from the rate of the occurrence
in the general population. A risk ratio of >2 or 3 is usually considered evidence
of an important risk. For example, a risk ratio of 5 would mean that the popu-
lation with the risk factor (e.g., those who are exposed to asbestos) are five times
RATE OF DISEASE: Number of cases of disease in population at dsk
Number of persons in population at risk
Expressed as Number of Cases

100 or 1000, 100,000 (usually) etc. persons at risk
Example: 50 Cases = 20
2500 persons at risk 1000
RISK RATIO: Rate of disease in population with the risk factor

Rate of disease in population without the risk factor
(comparison population)
Expressed as A numerical ratio (1.5, 3.0 etc. indicating that risk of disease
in the exposed (or at risk) population is 1.5, 3.0, etc. times
greater than that in the unexposed (or not at risk) population
Example: 20/1000 = 2.0

10 /1000
Figure 3.5 Definition and calculation of rates of disease and risk ratios.
RISK ASSESSMENT 113

more likely to have or get the disease (e.g., lung cancer) than the population
without the risk factor (e.g., those who were not exposed to asbestos).
A risk ratio, the most widely used form of risk measure, is defined as "the
ratio of the risk of disease or death among the exposed to the risk among the
unexposed" (Last, 1995). Data from case–control studies approximate the rel-
ative risk by a calculation known as an odds ratio. Other measures of risk, which
can be derived from epidemiological studies, are defined in Box 3.3. The risk
difference is "the absolute difference between two risks" (Last, 1995). It demon-
strates the excess risk of the health problem in the exposed population, by sub-
tracting the risk of the unexposed population from the risk of the exposed pop-
ulation. This is also known as the incremental risk. The attributable fraction
(exposed) describes the proportion of new cases of a disease in the exposed pop-
ulation that are due to the exposure—i.e., "the proportion by which the inci-
dence rate of the outcome among the exposed would be reduced if the expo-
sure were eliminated" (Last, 1995). The attributable fraction (population) describes
the proportion of new cases of a disease in the whole population that are due
to the exposure—i.e., "the proportion by which the incidence rate of the out-
come among the entire population would be reduced if the exposure were elim-
inated" (Last, 1995).
A commonly used method of evaluating mortality in a group of people is to
calculate the standardized mortality ratio (SMR) for the group, which is the ratio
of the observed deaths in a group divided by the number of deaths that would
normally be expected in a group with a similar age distribution. The SMR is ex-
pressed as follows:
SMR = Observed number of deaths (or events) in the study population X 100%
Expected number of deaths (or events) if the study population had the
same age and gender specific death rates as the comparison
(e.g., national) population
The denominator of the SMR (e.g., the expected number of deaths) is computed
as follows:
l• A calculation is made of the person-years at risk in the cohort for each agel
gender group (the sum of the number of years that each individual in the co-
hort has been followed).
The figure obtained is multiplied by the expected age/gender specific mortal-
ity rate for the disease(s) being ccnsidered based on national health statistics.
The expected number of cases is the sum of cases in the age/gender groups.
An SMR of 130 for a particular cause of death indicates that there was a 30%
greater mortality of that disease found than was actually expected.
Since these measurements of risk are statistical, we cannot be sure that the
observations in a study did not occur by chance. The statistical variation of these
measures is usually expressed as the confidence interval. The 95% confidence in-
terval is the range within which the true value lies, with 95% probability. The

B()X 3.3
Common Measures of Risk Derivable from
Epidemiological Studies
Risk difference = E-U

E
Risk ratio =
U
(E — U)
Attributable fraction (exposed) = - = (through mathematics) (RR-1)
E RR
[—U [p(RR-1)]
Attributable fraction (population) = - =
I Fp(RR - 1)+1J
where U = incidence (or mortality) in the unexposed group; E = incidence (or mor-
tality) in the exposed group; p = prevalence of exposure at a designated time preva-
lence in the total population; 1= incidence in the total population; and RR = risk
ratio.
When the size of the total population at risk is not known, e.g., in case—control
studies, the RR can he estimated by calculating the odds ratio (OR). Consider the
following notation for the distribution of a binary exposure and a disease in a pop-
ulation divided into four groups: individuals with disease and exposed (A), with dis-
ease and unexposed (C), without disease and exposed (B), and without disease and
unexposed (D). The OR would be calculated as follows:
Disease
Exposed Yes No
Yes A B
No C D
Thus
OR = Lc
B/C
true effect is most likely to be the mean or central tendency of the confidence
interval but it may be larger or smaller; 95% of the time, however, it will fall
within the range calculated as the confidence interval. There is also a 5% chance
that the true value lies outside the confidence interval; that is, it is higher or
lower than either extreme valtie of the confidence interval. The width of the con-
fidence interval depends on the number of cases observed, the size of the pop-
ulation in the study, and the variability of the comparison or expected rates.
These issues are discussed at greater length in Basic Epidemiology (Beaglehole et
al., 1993) and other standard epidemiology texts.
RISK ASSESSMENT 115

Study Difficulties and the Determinants of Causation
In determining the degree of weight that should he placed on the evidence ob-
tained from an epidemiological study, it is necessary to distinguish between the
concepts of association and causation. Association means that the risk factor occurs
often (more than expected) where the disease appears. Causation means that the
risk factor plays a role in the events leading to the disease. A causal relationship
implies that the disease has been shown to be actually induced by the environ-
mental agent. There are numerous reports in the scientific literature alleging links
between environmental agents and disease outcome that have turned out to he
spurious. Therefore, guidelines are needed to assess the likelihood that the asso-
ciation is a cause-and-effect relationship (The most widely accepted were origi-
nally conceived by British statistician Sir Austin Bradford Hill, and are shown in
Table 3.3). These guidelines are not absolute but are useful in achieving con-
sensus about whether a known risk factor is likely a true cause of the disease in
question. It takes several studies to prove causal relationships. Because epidemi-
ological studies cannot be controlled in the same way as laboratory experiments,
they are always subject to greater uncertainty and require useful interpretation.
A major limitation of most studies is the statistical possibility that a real as-
sociation will be detectable in the study. The study has to be large enough to al-
low for a sufficient statistical power. For example, to detect a twofold increase
in major congenital malformations (with 95% certainty that an increase found
was not a chance finding, i.e., a = 0.05, and with an 80 0/u chance of finding a
true increase if it is indeed present, i.e., b = 0.20), more than 300 live births
would have to be studied, as shown in Table 3.4. Guidelines for the calculation
of statistical power have been published by the WHO (Lerneshov et al., 1990).
Cluster Investigations and Ecological Studies
In their daily practice, health services staff are regularly confronted with clusters
of disease that raise concerns about possible relationships to environmental fac-
tors. A cluster of disease is the occurrence of an unexpectedly high number of cases
in a given geographical area, period of time, and/or population. An example of a
geographic cluster is the relatively high occurrence of childhood leukemia in a
TABLE 3.3
TESTS OF CAUSATION
Temporal relation: Does the cause precede the cifect? (essential)
Plausibility: Is the association consistent with either knowledge?
Mechanism of action: Is there evidence from experimental animals?
Consistency: Have similar results been shown in other studies?
Strength: What is the strength of the association between the cause and the elfect? (relative risk)
Dose—response relationship: Is increased exposure to the possible cause associated with increased
effect?
Reversibility: Does the removal of a possible cause lead to reduction of disease risk?
Study design: Is the evidence based on a strong study design?
Judging the evidence: How many lines of evidence lead to the conclusion?
Source: Bcaglehole et at., 1993 (these are modified criteria of causation from those originally developed by
Bradford Bitt).

TABLE 3.4
SAMPLE SIZE REQUIRED TO DETECT A DOUBLING OF BACKGROUND
INCIDENCE IN REPRODUCTIVE OUTCOME
Reproductive Outcome Size of Each Group Required°
Infertility 161 couples
Spontaneous abortion 161 pregnancies
Stillbirth 161 pregnancies
Low birth weight 293 live births
Major birth defects 316 live births
Infant deaths 928 live births
Severe mental retardation 4493 live births
Chromosome abnormalities 8951 live births
With atpha = 0.05; beta 0.20.
Source: NIOSH, 1988.
rural community using well water contaminated with pesticides. The increased
occurrence of respiratory problems during a summer smog period can be seen as
a cluster in time. An increased occurrence of lung disease in workers at a par-
ticular workshop is a cluster in the population.
Clusters thought to relate to environmental factors sometimes receive a lot of
publicity. However, many clusters are actually not real, because the presumed
diagnoses are incorrect or misunderstood. Others are just chance events. For other
clusters, there may be explanations other than a common environmental expo-
sure because the exposure cannot account for the cluster.
A basic approach has been developed to investigate reported clusters as effi-
ciently as possible. The objective is to verify expediently (1) if a cluster truly ex-
ists or if it is a coincidence or merely false; (2) if human exposure to a possible
environmental hazard actually exists; and (3) if the relationship between these
two merits further investigation and/or action. Even if the answer to the first
two questions is yes, it still remains to be determined whether there is a causal
relationship between the increased number of diseased individuals and the rel-
atively high exposure levels. Each question nccds to be pursued independently,
because each requires further action if positive, even if the other is negative.
An ecological study is one in which the unit of analysis is the population group
or region, rather than the individual. Typically, regions involve persons living in
a geographic area such as a census tract, country, or province. For each group
or region the average exposure level to the agent in question and the rate of dis-
ease in question are determined independently. It is not known whether the in-
dividuals who have been exposed are the same individuals who developed the
disease. Because the exposure levels of individuals are not linked to the disease
occurrence in the same individuals, ecological designs are incomplete as evidence
for causal association, although they may be very useful for generating new hy-
potheses or proposed associations that can be tested in other studies. Ecological
studies arc also an inexpensive option for linking available health data sets or
record systems to environmental data. Other important variables are often avail-
able in these studies, such as sociodemographic and other census variables. Fig-
ure 3.6 illustrates the findings of an ecological study of the relationship between
RISK ASSESSMENT 117

200
C)
C) • S S
C) •
100
S
U) as • • •• S
CL • S •
ci) •
• • S
S S•
CU •
-C S• • S
. S.
S
CU
U) • . . . S
0 • S •'•S
. • :•. •
D
ci) .
N S •S • .
-D •
CU
• S • .• •• I
-D
• S S
CU
• • ,:.. •,
U) •S.
C)
• • •
•S .
• S
101 i I I I I I I I I I
3.5 4 4.5 5 5.5 6 6.5 7 7.5 8 8.5 9 9.5 10 10.5
Salt sold (kg / person I year)
Figure 3.6 Study of the relationship between salt sold in Chinese counties and esophageal
cancer mortality rates. From Beaglehole et al., 1993, with permission.
salt sold in a county (local government area) and escphageal cancer mortality
rates. Ecological studies can be classified into five basic design types that differ
according to the method of study selection and methods of analysis: exploratory
studies, space—time cluster studies, multiple groups studies, time trend studies,
and mixed studies.
HA7API) IDENTTFICATION IN THF FJELD
From toxicological and epidemiological data, potential health effects of hazardous

substances can be estimatcd. Recognizing hazards in a specific industrial pollu-
tion situation, however, requires a different approach. This is commonly done
by conducting health hazard evaluations and hazard audits, both of which involve
walking through the plant (or community facility) and investigating all opera-
tions. The difference between the two is that in a health hazard evaluation the
walk-through is intended to identify the cause of a particular problem but in a
hazard audit all potential hazards are systematically examined.
Occupational Environment
In the workplace it can be relatively easy to make an inventory of all potential
hazards. This is made easier by an accurate registration or tracking system of all
chemicals that are frequently used or stored, which unfortunately is not always
available. To make an inventory of chemical hazards, product identity is, of
course, crucial. From knowledge of which product is used, one may then learn
what is in it and what constituents are hazardous. Identifying the chemicals in

a product may be difficult if the manufacturer is not required by law to list in-
gredients or if the material is not labeled properly (see Chapter 2, Information
on Toxicily), or if the composition of the product is protected as a trade secret.
General Environment
When a point source of pollution is suspected, such as a specific industrial plant,
the hazards may be established on the basis of the type of materials used and the
industrial processes involved. The identity of chemical hazards is usually difficult
to determine in uncontrolled environments, such as illegal dumping sites or aban-
doned industrial locations. For example, the chemical hazards at a suspected soil
contamination may be from almost anything. One approach is to check whether
there is information within the community regarding former industrial or other
activities at the suspected location. Depending on the results of such an inquiry,
further research can be streamlined in a specific direction. However, if no records
exist or no industrial activities can he described by former workers, the situation
becomes far more difficult. In such a situation, chemical analysis of samples will
have to be conducted to determine the nature of the contamination. Since it is
too costly to screen for all possible contaminants, chemical analysis has to be con-
centrated on specific marker components. For instance, analysis of benzopyrene
may he used as a marker for contamination with polycyclic aromatic hydrocar-
bons, dieldrin for pesticides, and toluene for volatile organic compounds. All such
screening methods have their limitations.
RELATIONSHIP BETWEEN DOSE AND HEALTH OUTCOME
Dose-Effect and Dose-Response Relationships

The terms dose-response and dose-effect are occasionally used interchangeably.
Strictly speaking, however, a dose-response relationship is one between the dose
and the proportion of individuals in an exposed group that demonstrate a de-
fined effect (Fig. 3.7). A dose-effect relationship describes that between the dose
and the severity of a health effect in an individual (or a typical person in the
100
80
Z- 60
C
0
C-
40
cr
20
Figure 3.7 Dose—response rela-

tionship. From Beaglehote et
at., 1993, with permission. Dose
RISK ASSESSMENT 119

Degree of
Effect
Death
Unconsciousness
Nausea,
blackouts
Headache,
dizziness
Slight
headache
0 10 20 30 40 50 60 70 80
Carboxyhaemoglobin in blood (%)
Figure 3.8 Dose-effect relationship. From Beaglehole et al., 1993, with permission.
population) (Fig. 38). A hicrarchy of effects on health can be identified for most
hazards, ranging from acute illness and death to chronic and lingering illnesses,
from minor and temporary ailments to temporary behavioral or physiological
changes, as shown in Table 3.5. Dose-response relationships are considerably dif-
ferent for non-carcinogens (thought to have a threshold) and carcinogens
(thought to be non-threshold) as discussed further below.
Calculating Risks for Threshold Effects
Many environmental hazards have a specific effect on individuals only when the
dose reaches a certain level, i.e., a threshold for that effect. Figure 3.9 illustrates
the dose-respunse relationship for various health effects of lead concentrations
in blood in children. Sometimes the number of years of exposure has to be used
as an indicator of dose, when duration and levels of exposure are not known.
When concentration and dose are known, a dose index can be calculated. This
was done for workers in a Swedish battery factory (Kjellström, 1986b). Figure
3.10 illustrates how increased years of exposure to cadmium and average expo-
sure level (mg/rn 3 ) relate to high levels of 2 -microglobulin in the urine (>290
rg/liter), a measure of kidney dysfunction.
Dose-response relationships can also be obtained for physical hazards. Figure
3.11 illustrates the relationship between sound levels at work and the percent-
age of those with impaired hearing according to the age of the vvorkforcc. This
figure shows that the dose-response relationship is different in the different age-
groups.

TABLE 3.5
RANGE OF EFFECTS ON HUMAN
HEALTH DUE TO ENVIRONMENTAL
EXPOSURE
Premture death of many individuals
Premature death of any individual
Severe illness or major disability
Chronic debilitating disease
Minor disability
Temporary minor illness
Discomfort
Behavioral changes
Teniporary emotional effects
Minor physiological changes
Dose—response relationships also apply to injuries. As shown in Figure 3.12,

speed is used as an indicator of dose. With an increase in speed there is an in-
creased risk of nonfatal injury in car drivers in a collision. This figure also shows
that using seatbelts reduces the risk of injury by about 50%.
The concept of the dose—response relationship extends to psychological dis-
tress as well. As shown in Figure 3.13, the greater the noise level, the greater
the percentage of people annoyed by it. At a given noise level, a higher level of
annoyance was found in a U.S. Environmental Protection Agency (EPA) study,
than that found by another investigator.
Thresholds and Other Important Benchmarks

A no observed adverse effect level (NOAEL) is the point on a dose—effect curve at
which a threshold is reached. Before this level, there are either no symptoms or
our technology is not sufficient to detect a problem (depending on the situation).
These levels are often determined in animal studies. Similarly, a lowest observed
adverse effect level (LOAEL), is the lowest level at which some symptoms are found
100
C)
Ct
E
a)
80
C /
0
0
C 60
I /
/
Figure 3.9 Dose—response curve

0)
>..
D
I /
! /
for various health effects of lead in E 40
children. - - decreased cr-ALA D
II)
activity; - - increased ZPP, ...... 0
20
C
anemia; effect on the CNS; a)
a)
decreased nerve conduc- >
a) ol
tion velocity; - - palsy, colic 0
pain, encephalopathy. From Elm- 0 200 400 600 800 1000 1200 1400
der et al., 1994, with permission. Concentration of lead in blood (pg Pb! L)
RISK ASSESSMENT 121

100
130
7 .
75
36 Figure 3.10 Dose—response re-
C)
-c
lationsliip for cadmium expo-
50
sure and prevalence of high uri-
U)
C), 30 nary levels of /32 -microglobulin
c
0
a- 68 2 - m >290 .tgIIiter) The dot-
ted line indicates a maximum
25
possible response if all retired
26 and deceased workers with
65 dose index above 12.5 had a
0 I high 132 -microglobulin. From
0.5 1 2 5 10I 20
I 50 100 Kjellström, 1986b, with per-
Dose index (mg I day) x years mission.
(see Fig. 3.14). A no observed effect level (NOEL) is the level at which no effect, ei-
ther good or bad, is detected.
Because all individuals are constantly exposed to certain levels of environ-
mental chemicals, the question to address is what levels of exposure to these
chemicals are likely to affect human health. This analysis is usually done by of-
ficial agencies (e.g., the Environmental Protection Agency in the United States),
by applying animal and epidemiological studies. From these studies, an acceptable
daily intake (ADI), or tolerable daily intake (TDI) (depending on the jurisdiction),
is calculated. These values indicate the maximal daily intake of a chemical that
VLsI
• Factory workers
[;I.1 o General population
Age
50
55 - 59
40
(0 40-46
E
30
()
0)
0
30-39
Ce
2O-29
10
Figure 3.11 Dose—response relation-

ship between occupational sound lev-
els and prevalence of impaired hear-
65 75 85 95 105
ing for different age groups. From
Sound Level at Work dBA WHO, 1980a, with permission.

40
35
30
>. 25
' 20
>'
0
C
a)
0 15
a) Non-fatal injuries /
U-
NOT BELTED /
10 /
/
,x
Figure 312 Dose—response re- 5 x Non-fatal injuries
lationship between speed of a //BELTED
car in a collision and risk of dri-
ver injury for seat belt use and 0
0 25 50 75 100 112
non-use. From Beaglehole et
al., 1993, with permission. Speed (km / h)
is not expected to result in adverse health effects after a lifelong exposure. The
ADI is usually the NOAEL (or LOAEL) divided by uncertainty factors (UF) (which
are discussed below):
ADI = NOAEL (or LOAEL

UF
The ADIs can then be used as reference values in establishing guidelines to pro-
tect individuals. Note that time and dosimetry factors (such as body weight, sur-
face area, and absorption rate) must be specified for an ADI. For example, an
ADI is often prepared for a person of 70 kg who is exposed to a chemical for 3
hr/day. The ADI5 and TDI5 are often revised over dine, as new information is
discovered through further studies. Examples of TDIs are given in Table 3.6.
Uncertainty Factors in Establishing Th re.c holds

Generally it is not possible to specify an exact threshold for any substance, for a
variety of reasons: the vulnerability of individuals varies; there is considerable
physiological diversity in human populations; measuring techniques have their
limitations; study methods are often limited; at very low exposures, the effects
may not he easily detectable; and data relating to the upper end of the curve
may also be difficult to obtain because massive exposures are relatively rare.
Nonetheless, the principal use of dose—response curves is to predict the conse-
quences of very high and very low exposures.
The extrapolation of animal data to humans has a number of fundamental
problems. First, the effect on the animal studied may simply not apply to hu-
RISK ASSESSMENT 123

80
70
/1
60 /
/
/
USEPA(1973)
0
50
>
U)
0
/
C /
CU
/
40 /
I
0)
/
/ Schultz et al. (1976)
/
30 ,
,
,
,
20 ,
,
/
,
10
I-
000
0
40 50 60 70 80 90
Day time L eq or L dn (dB(A))
Figure 3.13 Dose—response relationship between outdoor noise level and annoyance. From
WHO, 1980a, with permission.
No Threshold
Response ,
I
Threshold
Response
LOAEL
NOAEL
Increasing Dose of Substance
Figure 3.14 No observed adverse effect level (NOAEL): the level of exposure to a chemical
at which no adverse effects were observed during studies with animals. Lowest observed
adverse effect level (LOAEL): the lowest level of exposure to a chemical at which adverse
effects were observed during studies with animals. From HC, 1993, with permission.

TABLE 3.6
TOLERABLE DAILY INTAKES OF ENVIRONMENTAL
CHEMICALS
Non-Carcinogen Tolerable Daily Intake
Copper 0.05-0.5 mg/kg/day
Endrin 1.0 ag/kg/day
Lead in adults 7.14 j.cg/kg/day
Lead in infants 3.57 pg/kg/day
Mirex 0.028 p.glkg/day
Methyl Hg 0.47 ftg/kg/day
Total Hg (methyl Hg+ inorganic Hg) 0.71 cg/kg/day
Tin _2 mg/kg/day
Source: HC, 1993.
mans becausc of physiological differences between the species (as discussed in

Chapter 2). Second, projections from a higher-dose response range to a lower-
dose range involve various assumptions that may not prove to be accurate. Third,
animal studies are often conducted using routes of administration that do not
correspond to the routes of human exposure.
The safety (or uncertainty) factor (UF) reflects the degree of uncertainty that
must be incorporated into the extrapolation from experimental data to the hu-
man population. When the quality and quantity of dose—response data are high,
the safety factor is low. When the data are inadequate or equivocal, the safety
factor must he higher. (Safety factors are not relevant to carcinogens, however,
as discussed below.) The National Academy of Sciences (NAS) Safe Drinking Wa-
ter Committee and the EPA in the United States have developed the safety fac-
tor guidelines shown in Table 3.7. An example of an application of a safety fac-
tor to calculate an ADI is provided in Box 3.4, although in this example the
calculation is extended to give information about the accepted dose from water
intake, not just intake from all sources combined.
Figure 3.15 is a generalized dose—response curve showing how risks at the
lower levels of exposure may he estimated by extrapolating from middle-range
observations. The solid line to point A is the dose—response curve, determined
TABLE 3.7
SAFETY OR UNCERTAINTY FACTORS
Factor Comments
lOX factor Applied to data from valid experimental studies on prolonged human intake.
This protects the Sensitive members of the population.
lOOX factor Applied when experimental results from studies of human intake are not avail-
able, or are inadequate but there are valid results from low-dose intake stud-
ies on one or more species of experitnental animals. This accounts for species-
to-species extrapolation.
1000)< factor Applied when there are no low-dose or acute human data and only scanty
results on experimental animals. This is applied to account for spectes to
species extrapolation, from high dose to low dose, and from short-term to
long-term effects, as well as protecting sensitive members of the population.
RISK ASSESSMENT 125

BOX 3.4
Calculation of Acceptable Daily Intake
Animal studies of various doses of para-dichlorohenzene have shown hepatic and

nephrotoxicity as well as pulmonary damage and other effects. A 1-year gavage (di-
rect exposure into the stomach) study in rabbits using groups of five animals dosed
between 0 and 1000 rng of para-dichlorobenzene per kg of body weight per day for
5 days per week resulted in weight loss, tremors, and liver effects. The highest no
observed adverse effects level (NOAEL) was 357 mg of para-dichlorobenzene per kg
per day. A subchronic study indicated a NOAEL of 150 mg of para-dichlorohenzene
per kg of body weight in the rat exposed by gavage, and this number was used for
calculating an ADI for humans. The provisional AOl was computed as follows:
[Remember ADt = NOAEL/(safety factor) taking dosimetry factors into account]

ADI = (150 mg/kg of body weight/day) >< (70 kg/person)
X (5 daysl7 days/week)/(lOO X 10)
= 7.5 mg/person/day.
One hundred is the safety factor appropriate for use with a NOAEL from animal
studies with no comparable human data; ten is an additional safety factor because
the duration of exposure in the experiment was significantly less than a lifetime.
As no data were available on the contributions of food and air to exposure, an
arbitrary designation of 20% was chosen as the maximum allocation from drinking
water. If the daily water intake per person is assumed to be 2 liters per day, the al-
located ADI (AADI) for water is:
AADt = ADI >< water allocation/(2 liters/day)

= 7.5 mg/day X 20%/(2 liters/day)
= 0.75 mg/liter
This number represents the maximum amount of para-dichlorohenzene that an in-

dividual can ingest from water in I day with relative assurance that the individual
will not have any ill health effects. Caution must be made in interpreting this num-
ber, because of the multiple assumptions, extrapolations, etc., that have been used
to create it.
Source: do Koning, 1987.
by a multiple dosing experiment. Curves AB, AD, and AE are possible dose-
response curves at lower doses, with points B, D, and E being the respective
threshold for adverse effects in the human population. In setting an ADI con-
centration (point C), a selected safety or uncertainty factor is applied to the dose
at point A. If the curve AB is the true effect curve, then the calculated ADI value
will be lower than the threshold dose, thus indicating that the safety factor was
appropriate. However, if AD or AE is the true dose—effect curve, then the calcu-
lated ADI will be too high and the safety factor too small. In this case, some in-

U,
CE
Figure 3.15 Dose—response

curves showing different pos-
sible estimates at lower dose
levels. From de Koning, 1987,
B
with permission. E D C
Dose
dividuals in the population will suffer adverse effects. The size of the gap be-
tween points C and B is also of interest, because if it is large, expenditure on
control methods may be greatly in excess of what is needed.
Once the threshold dose for a toxic substance has been determined for the
normal and healthy population, consideration must be given to high-risk groups
such as infants, young children, elderly people, pregnant women and their fe-
tuses, the nutritionally deprived, the ill, individuals with genetic disorders, and
those exposed to other environmental health hazards. There are many examples
of the susceptibility of these high-risk groups. The increased susceptibility of fe-
tuses and infants has been well documented. For example, several Japanese chil-
dren born to mothers exposed to methylmercury in fish in Minamata suffered
congenital malformations even though the mothers showed few or no symptoms
of mercury poisoning at all. The fact that nutritional deficiencies increase suscep-
tibility is also well documented. Dietary deficiencies of calcium and iron signifi-
cantly intensify the toxicity of lead. Individuals who suffer from kidney disease,
for example, will experience greater effects from exposure to toxic metabolites
that require excretion through the kidneys, and impaired liver function affects the
inctabolic conversion, particularly detoxification of certain pollutants or their ex-
cretion in bile. Individuals suffering from cardiovascular or respiratory disease are
at greater risk from the effects of carbon monoxide or sulfur dioxide. It may there-
fore be necessary to apply an additional safety factor to the dose that is toxic to
the general population, in an effort to protect susceptible groups.
Calculating Risks for Non-Threshold Effects

Individuals either get cancer or they do not, and the probability is of an all-or-
nothing event. A higher exposure does not result in a worse cancer but in an in-
crease in the likelihood of getting it. Likewise, a lower level of exposure does not
mean that the magnitude of the effect is less, so the dose—effect curve is consid-
ered irrelevant to assessments involving carcinogens. The dose—response curve,
however, is very relevant, and it is generally agreed that the dose—response curve
which does not assume a threshold is thus the preferred tool for analyzing risk
associated with exposure to carcinogens. The argument against a threshold is that
a single point mutation of the DNA can lead to an uncontrolled growth of a so-
RISK ASSESSMENT 127

matic cell that eventually produces cancer. It can be argued that different indi-
viduals have different thresholds because of differences in DNA repair genes and
immune defenses, but these are not easily testable hypotheses.
In the multistage model of carcinogenesis, discussed in Chapter 2, a cell line
must pass through several stages before a tumor is irreversibly initiated. The rate
at which cell lines pass through these stages is a function of the dose rate. In the
multihit model, dose relates to the number of hits to the sensitive tissue required
to initiate a cancer. The most important difference between the multistage and
the multihit models is that in the multihit models, all hits must result from the
dose, whereas in the multistage model, passage through some of the stages can
occur spontaneously. The multihit models predict a lower risk at lower doses
than that predicted by the multistage model. Aside from the one-hit, the multi-
hit, and the multistage models, there are other models that explain dose—response
relationships between carcinogens and cancer. The different models are each as-
sociated with different dose—response curves.
Just as one can produce an ADI for threshold agents such as mercury, one
can produce a risk-specific dose for non-threshold agents, such as radon. In the
case of a threshold agent, as described above, the NOAEL can aid the agency re-
sponsible for setting the ADI. In the case of a non-threshold agent, at any con-
centration of the agent cancer will be caused in some individuals in the popula-
tion. Thus it is usually desirable to reduce the agent to the lowest possible level,
realizing that it is impossible to eradicate it entirely. In setting a guideline value,
an acceptable level of risk (ALR) must be determined. This is essentially a judgment
call, which may or may not be made with the input of the people who are con-
cerned in the community. In some countries, one fatality in a million people at
risk is considered to be an acceptable level of risk for many situations, but there
may he circumstances in which a greater risk, for example, 1 in 100,000, may
be considered tolerable if the risk is balanced by a very considerable benefit. It
should be noted that an increase in mortality in the general population at such
a small rate would be virtually impossible to detect with current epidemiologi-
cal techniques. One in 10,000 would he more customary for occupational expo-
Sure 5.
HUMAN EXPOSURE ASSESSMENT

Options in Approach
Human exposure is defined as the opportunity for absorption into the body or ac-
tion on the body as a result of coming into contact with a chemical, biological,
or physical agent. The various routes of exposure have already been introduced.
The units of exposure to a chemical are usually the concentration multiplied by
time (e.g., mg/ml/hr). The term total exposure implies that an attempt is being
made to take into account all exposures to the contaminant regard]css of media
or route of exposure. As shown in Figure 3.16, exposures from air, water, food,
and soil form the link between hazards and effects.
The critical parameter with respect to health effects is actually the dose, since
it directly identifies the amount of the contaminant that has the potential to at-

Traditional Hazards Modern Hazards
Human acOvuies Development ac5vltlnn
Natural phenomena
Emissions
I __
Environmental Concentration
Air Water Food Soil
N \ / -Z
Exposure
External Exposure
$
Absorbed Dose
$
Target Organ Dose
Health Effects wk
Figure 3.16 Contaminant Subclinical Effects

sources and effects contin- $
uum. From Corvalan and Morbidity
Kjellstrom, 1995, with permis- $

Mortality
ston.
tack the target organ. Internal dose refers to the amount of the contaminant ab-
sorbed in body tissues upon inhalation, ingestion, or absorption. The biologically
effective dose is the amount of the absorbed or deposited contaminants that con-
tributes to the dose at the target site where the adverse effect occurs. Total dose
is the term used to indicate the sum of all doses received by a person of a con-
taminant over a given time interval from interaction with all media.
Because the dose is difficult to measure, the parameter usually considered is
the exposure. Therefore, regulators usually establish rules and regulations that
are directly linked to reducing exposure, as opposed to dose. Estimates can then
be made of the dose, based on the exposure, various assumptions, and animal
models. While such estimates often have large uncertainties, it is a more practi-
cal parameter than dose. In any case, it has to be clear that measuring exposure,
not just environmental concentration, is the critical parameter since it is more
directly related to health effects. To put it simply, if someone is not inhaling, in-
gesting, or absorbing the pollutant, there is no exposure and hence no adverse
health effect is possible. In all such investigations the total exposure from all
sources must be assessed and not just the concentration in the medium or cir-
cumstance of concern. Exposure is usually measured for just one medium at a
time. Risk assessment that is intended to optimize mitigation strategies must es-
RISK ASSESSMENT 129

Exposure Analysis
Assessment
Indirect
Direct Methods
Methods
Personal Biological Environmental I Models I' Questionnaires

' Diaries
Monitoring Markers Monitoring i i
Pharmacokinetics and
Pharmacodynamic models
Exposure
Models
Figure 3.17 Direct and indirect approaches for the analysis of exposures. From NRC, 1991,
with permission.
tablish the relative risks associated with absorption from all media and routes of
entry in order to gain a clear picture of which is more important.
Monitoring may be direct and indirect, as indicated in Figure 3.16. Personal
environmental monitoring and biological monitoring are considered direct ap-
proaches; environmental area monitoring as well as questionnaires, diaries, and
mathematical models are considered indirect.
Assessment of exposure can be made in different ways, as illustrated by the var-
ious points along the continuum described in Figure 3.17. Environmental monitoring
irieasures concentrations of contaminants to which individuals may be exposed. Bi-
ological monitoring usually measures dose, or more specifically, body burden at a point
in time. Each of these can be further subdivided into area sampling, which measures
concentrations without taking into account the extent of actual exposure, and per-
sonal sampling, which measures more directly the concentrations to which an indi-
vidual is exposed throughout a period of time. Similarly, biological monitoring can
also be further subdivided to reflect the extent to which the biological marker being
sampled is a measure of dose, a marker of effect, or a marker of susceptibility.
Personal Exposure Monitoring
Personal air-monitoring devices provide direct measurements of concentrations
of air contaminants in the breathing zone of an individual. Generally, samplers
worn by subjects record time-integrated concentrations, reading concentrations
directly, or they collect time-integrated samples that require lab analysis. Sam-
plers may either be active, requiring a pump to move air, or passive, requiring
no pump and collecting the airborne contaminant by diffusion.
For watcrbornc contaminants, a direct measurement entails sanipling from
the water source, such as a drinking tap, or from the water actually drunk. To
measure food contaminants, duplicate meals are analyzed. In this method, an in-
dividual must collect a second portion of everything consumed. This duplicate
meal is then homogenized and analyzed for the compounds of interest.

Direct measurements of skin exposure in an occupational environment have
been carried out by attaching patches on the skin. After a working day, the
patches are removed, extracted, and analyzed. The effectiveness of using gloves
to protcct skin exposure can be established in a comparable way. Cotton gloves
worn underneath latex gloves can be analyzed for specific chemical agents ab-
sorbed during handling. The results should indicate whether and to what extent
the compound of interest can penetrate the gloves. These results can indicate
how frequently gloves should be changed to prevent exposure.
Biological Monitoring of Exposure or Effect

In biological monitoring, the contaminant of interest, its metabolitc (see Chapter
2), or the product of interaction between it and some target molecule or cell is
measured in the relevant body tissue. If lead is the contaminant of interest, for ex-
ample, area sampling can be conducted to determine the operations associated with
the greatest lead concentration; personal air monitoring for lead exposure may be
conducted, blood lead levels may be drawn from exposed workers to measure dose,
or a marker of effect such as free erythrocyte protoporphyrin (FEP) may be eval-
uated. Examples of some biological markers of exposure are shown in Table 3.8.
A marker of effect must be a measurable, biochemical, physiological, or other
alteration within an organism that, depending on magnitude, is recognized as re-
lating to the potential to cause health impairment or disease (NEC, 1991). Some
markers of effect signal preclinical or presymptomatic stages in disease develop-
ment, whereas others signal adaptive changes that are not themselves patholog-
ical. This often presents a difficult clinical situation—für example, with respect
to workers' compensation (see Chapter 10). Workers maybe told that they have
an elevated leveled FEP, but they have no clear symptoms of lead poisoning. In
most jurisdictions, this case would not be considered compensatable by a work-
ers' compensation board. Also, these markers may be complicated by various in-
terpretations and confounders. For example, PEP levels may be proportionally el-
evated because of iron deficiency. Or, although the presence of carboxyhemoglobin
(COHb) in blood signals that carbon monoxide exposure is occurring, the source
could be the inhalation of carbon monoxide or the metabolism of methylene
TABLE 3.8
EXAMPLES OF USEFUL MARKERS OF EXPOSURE
Substance Biological Marker
Carbon monoxide COHb in blood
Cadmium Cadmium in urine
Lead Lead in blood
Methyl-mercury (in fish) Mercury in hair
PCP PCP in urine
Alcoholic beverages Ethanol in exhaled breath
Organic so]vents Mttaboliies in urine
VOCs VOCs in exhaled breath
Tobacco smoke Colinine in urine
COi{tj, cart, xyhemoglobtn; PCP, pdntkht()111c1iot SOCs, volatile or-
'anics.
RISK ASSESSMENT 131

chloride. It may also be due to hemolytic anemia with increased breakdown of
hemoglobin.
Biological monitoring for susceptibility markers is a highly controversial area.
Markers of susceptibility may relate to induced variations in absorption, metab-
olism, and response to environmental agents. For example, measurement of air-
way reactivity to inhaled bronchoconstrictors can be used as a marker of sus-
ceptibility to asthma.
Recently, the application of markers in a rapidly developing field sometimes
called molecular epidemiology has attracted much interest. There has been particular
enthusiasm for the study of DNA and protein adducts. However, chemical meth-
ods to detect and quantify adducts often rely on costly methods that require highly
sophisticated and expensive instrumentation (such as gas chromatography and mass
spectrometry) operated by highly skilled technologists. Furthermore, most of these
methods still have to be validated and cannot be considered routine measurements.
Indirect Approaches to Estimation of Exposure

The indirect approach to estimating an individual's or a population's exposure to
a pollutant combines concentration measurements in the environment with in-
formation on human activities obtained through the use of questionnaires or di-
aries (see Fig. 3.17). Exposure assessment surveys, whether they be questionnaires,
telephone interviews, or measurements, usually attempt to obtain information in
four areas: demographic profile, health status, environmental factors, and time-
activity. There are three general approaches for obtaining time—activity informa-
tion. One is called the estimation approach, in which an estimate is made of the
amount of time spent by study participants in various activities during the time
period of interest. The second approach uses time activity diaries, in which partici-
pants are asked to describe all of the activities in which they were engaged during
the study period. The third approach is the observational approach, in which partic-
ipants arc monitored by outside observers. While this adds a degree of complete-
ness and accuracy to the data, many people may refuse to participate in a study
in which their activities are being monitored. Using data on concentrations in var-
ious environments and human activity data as input variables, calculation models
can predict exposures at an individual or population level. To estimate exposures
via different exposure routes, standard values for the amount of inhaled air and
ingestion of drinking water and soil can he used. One set of such standard values
is presented in Table 3.9 for various age-groups. The standard value for total soil
adhered can be used as a proxy measure for potential dermal exposure.
Estimating Inhalation Exposure

Outdoor measurements have been an integral part of environmental monitoring
in many countries for several decades. Indoor air was largely ignored however,
until the 1970s and 1980s. Thus, while many air pollutants are at higher con-
centrations indoors than outside, indoor air quality monitoring procedures arc
less well developed. This will be discussed further in subsequent chapters. To es-
tirnate an inhalation dose, an estimate of the amount of air a person breathes in
a day is required. A person's gender, age, and amount of physical activity are
major factors affecting the volume of air breathed. Age-specific standard values

TABLE 3.9
RECOMMENDED STANDARD VALUES FOR DAILY INTAKE OF
AIR, WATER, AND SOIL
Age Air Inhalation Water Inges tion b Soil Ingestion Total Soil Adhered
(years) (m 3/day)° (liter/day) (mg/day) (mg/day)
0—<0.5 2 BF: 0/0 35 2200
NBF: 0.2/0.8
0.5—<5 5 0.2/0.8 50 3500
5—<12 12 0.3/0,9 35 5800
12—<20 21 0.5/1.3 20 9100
20+ 23 0.4/1.5 20 8700
1000 liters I isa 1
.
The first value represents straight tap Water only', the secoitd includes tap water—based beverages such as tea,
coffee, and reconstituted soft drinks. Exclosivel breast-led infants (BFi do not require additional liquids. Estimates
for non—breast-fed infants NBF) are based on volume consumed as drinking water and on consumption of 750
mi/day of Ii irroula made from p iwdered formula and tapwater for total drinking water.
Source: HC, 1992.
are given in Table 3.9. Other factors influencing the volume of air breathed in-
clude temperature, altitude body weight, smoking habits, history of heart dis-
ease, and possibly background air pollution. The absorbed dose is dependent on
the deposition of the chemical in the respiratory tract and the absorption of the
deposited chemical into the bloodstream.
Estimating Ingestion Exposure

Water To estimate the exposure to contaminants from drinking water, the
amount of water people drink and otherwise consume (for example, by bathing)
must be determined. Ingestion of water includes plain water, water in coffee, tea,
or other drinks made with tap water, and water in cooked food. If precise val-
ues for a community are not available, standard values such as those presented
in Table 3.9 can be used. To calculate the water ingestion dose, it is usually as-
sumed that 100% of the contaminated water is absorbed after ingestion, and a
similar formula to that shown for inhalation is used.
Soil Soil can he eaten unintentionally when soil sticks to hands or to food. Soil
can also be ingested when other objects are put in the mouth or swallowed. All
children do this to some extent. The frequency that children swallow and put
objects in their mouths varies. Children between the ages of 1 and 3 years, and
children with iron deficiency or certain mental disorders develop a habit of swal-
lowing objects more often than other children (known as pica). Standard values
for the daily ingestion of soil by children who do not swallow objects regularly
and by adults are presented in Table 3.9. To calculate the soil ingestion dose, it
is assumed that 100% of the contaminant ingested with soil is absorbed. The
equation, however, should convert the concentration of the contaminant in the
soil (C) from ,ag/kg of soil to pg/kg of soil, so that the units for soil concentra-
tion are the same as those for soil ingestion.
food To determine the amount of a contaminant eaten with food, a knowledge

of eating habits of the group or population being studied is required, along with
RISK ASSESSMENT 133

the concentration of the contaminant in different kinds of food. Eating habits-
the amount of each different kind of food eaten—in a community may differ
from the national average or environmental estimates. To measure the amount
of contaminant absorbed into the body with food (estimated dose), a separate
calculation is carried out for each kind of food or food group eaten. Although
this equation looks more complicated, the extra steps are just a repetition of the
basic equation used in calculating all other estimated doses (ED).
Estimating Skin Exposure and Doses

The absorption of contaminants through the skin depends on a number of fac-
tors, including the following:
• the total surface area of the exposed skin

• the part of the body in contact with the contaminant
• the duration of contact
• the concentration of the chemical on the skin
• the ability of the specific contaminant to move through the skin into the body
(this is called the chemical-specific perme(7bility)
• the type of substance through which the contaminant comes into contact with
the skin (for example, whether the contaminant was dissolved in water or in
soil when it came into contact with the person)
• whether the skin is damaged in any way before coming into contact with the
contaminant.
The area of the skin that is exposed will he influenced by the activity being per-
formed and the season of the year. To estimate the absorption of a contaminant
in water through the skin, a permeability ccnstant (P) should be used. However,
such constants have been established for only a few chemicals. Even for chem-
icals that have been tested, the value of the constant can depend to a very large
degree on the design of the experiment used to test the chemical. Box 3.5 sum-
marizes the information needed to calculate estimated daily intake (EDT) via in-
gestion and skin absorption.
Principles of Population Sanip ling
In the selection of a population sample for human exposure assessment, a sam-
pling frame should be established, which should include (a) all the people in the
target population. or (b) areas and the approximate number of people linked to
each area. If the people in the target population are mobile, they may have to
be linked to the areas where they eat or sleep. Developed countries usually have
a central statistical bureau that maintains registries or conducts a population cen-
sus, which may form an ideal frame for sampling from the general population.
As these listings are rarely complete, sampling frames often need to be conducted
in stages, as discussed below, with these data constituting a sampling frame for
the initial stages of a multistage sample. In developing countries, where census
data are generally not available, special efforts may be needed to estimate the
population linked to the areas to construct a sampling frame.

BOX 3.5
Basic Equations for Calculating Estimated
Daily Intake (EDI) Via Ingestion and Skin Absorption
Ingestion EDT = C >< IgR >( EF/BW

Skin absorption (water) EDT = C X P X SA >< ET X EF/BW
Skin absorption (soil) EDT = C X A X BF >< EF/13W
where C = concentration of the contaminant; JgR = ingestion rate (usually

liters/day); P = permeability factor of the skin site; SA = surface area exposed; ET =
exposure time; EF = exposure factor; BW = body weight; A = total soil adhered (of-
ten need to use standard tables); and BF = bioavailability factors [percent of the
contaminant in the soil that is actually free to move out of the soil and through the
skin (unitless)l.
If the target population consists only of people with specific characteristics,

lists of these people may be available. For example, if the target population con-
sists of lactating mothers, clinics in the area may he able to provide lists of moth-
ers who have recently delivered babies. If available information does not provide
complete enough coverage of the target population, samples from the lists must
be supplemented with samples from other, possibly less efficient, frames that pro-
vide more complete coverage of the target population (see UNEP/WHO, 1993).
Figure 3.18 provides a visual representation of multistage sampling, in which
researchers begin by sampling relatively large units and work their way down to
increasingly smaller units. Using estimates of the number of people residing in
each area, a sample of the geographic areas is selected. At the next stage, either
the sample can be listed or smaller geographic areas can be listed within each
area selected at the first stage of sampling. At the final stage of sampling, a list
of the people residing in each sample area is prepared, and a sample of the peo-
ple is selected from the lists. For example, to select a sample of adults living in
a large city, researchers might (1) randomly select ten neighborhoods; (2) within
each neighbourhood, randomly select two urban blocks; (3) within each block,
select ten households; (4) within each of the households, select one adult for the
study. Methods for implementing simple random sampling and systematic sam-
pling are discussed in numerous other publications. In stratified random sampling,
an effective technique used to ensure that subgroups are adequately represented,
the subpopulation of special interest (e.g., people between certain ages) is sam-
pled at a higher rate than the remainder of the population to obtain sufficiently
precise results for that group. The total estimated dose is calculated by simply
adding these EDIs together. Note that the equations are very similar, except that
the rate of contact varies depending on the type of exposure.
RISK ASSESSMENT 135

/ City
....................
Urban Block
it1
Neighborhood
ic -
2.
- ......................
•\jJA1
Househqld
Figure 3.18 Multistage sampling procedures.

Participant From UNEPIWHO, 1992a, with permission.
Errors and Quality Assurance

The potential for errors in environmental exposure assessment is large. Errors
may occur with respect to the representativeness of sampling sites, the method
of sample collection, the analytic procedure, and data handling.
The representative error refers to whether the sample collected represents the
average concentration in the media under study. For example, an outdoor mon-
itor on the roof of a multistoried building may not yield the concentration data
needed to estimate average community air exposure. Even if sampling is con-
ducted at a reasonable site, there is always a question as to how representative
it is of exposure to residents at different times or when the wind blows from dif-
ferent directions. Portable sampling done in various directions and at variable
distances from a fixed site can often provide more accurate data.
Sample collection errors (e.g., for water, soil, or food samples) can usually be min-
imized by simply using containers that are free of the contaminant of interest. Air
samples are more difficult to properly collect and there is considerably more con-
troversy over which instrument to use in various situations. Industrial hygienists
therefore obtain considerable training in techniques of proper sample collection,
and only people trained in these techniques should conduct air sampling.
Analytical errors may arise from the use of improper calibration procedures, van-
ations in temperatures or line voltage in the laboratory, operator mistakes, as well
as the intrinsic imprecision and inaccuracy of the analytical method chosen.

Finally, errors in data preparation may occur at a number of stages and often
relate to the number of individuals involved in obtaining an environmental mea-
surement. These specialists include the field person who collects the sample, the
laboratory technician who does the analysis, the computer programmer who en-
ters the data, and the epidemiologist who, often with the help of the statistician,
interprets the data.
Quality assurance programs have therefore been developed and much interna-
tional guidance has been provided on this subject. Effective procedures include
the use of standard reference materials when calibrating instruments, monitor -
ing of the line voltage and temperature to keep them constant, and duplicate
analyses of some of the collected samples. A number of methods have been em-
ployed for quality assurance, such as interlaboratory comparisons, in which dif-
ferent analytical methods are used to analyze the same sample, and various sta-
tistical procedures to highlight bad data or extreme values.
Ensuring Adequate Sample Size

Determining an appropriate sample size requires balancing precision and cost.
When the cost of a study is high, it may not he possible to obtain a very large
sample size. Guidelines for calculating necessary sample sizes for accurate esti-
mates are available in many textbooks and WHO publications, including that by
UNEP/WHO (1993). Even if the final sample sizes are determined primarily by
cost constraints, rather than for desired precision, it is essential to calculate the
precision that is expected for important parameter estimates and the power ex-
pected for important hypothesis tests. Studies that do not meet minimum stan-
dards for reliability of inferences are not useful—they cannot be interpreted. In
general, a sample size of 50 persons is the minimum acceptable for human ex-
posure–monitoring studies, with a range of 250 or more people considered de-
sirable. The problems regarding inferences to the target population must be dis-
cussed in the reports of all studies but this is particularly important for studies
with small sample sizes. Such problems include (1) unreliable point estimates,
(2) unreliable estimates of precision, and (3) lack of normality for interval esti-
mates and hypothesis tests (see UNEP/WHO 1993 for greater detail).
HEALTH RISK CHARACTERIZATION
General ApproaL
Risk characterization brings together the first three components of the risk assess-
ment process: hazard identification, dose–response assessment, and exposure as-
sessment. The incidence and severity of potential adverse effects are estimated
as well. The major assumptions, scientific judgments, and uncertainties are de-
scribed in detail to fully understand the validity of the estimated risk. Risk char-
acterization (or risk estimation as it is also known) may be subdivided into four
different steps as indicated in Table 3.10.
The first equation of total exposure combines the concentration of pollutants
(by direct measurement through sampling and analysis, modeling, analysis of bi-
ological markers, and questionnaires) with the duration of exposure, expressed ac-
RISK ASSESSMENT 137

TABLE 3.10
CONSECUTIVE STEPS IN HEALTH RISK CHARACTERIZATION
Step Description
Exposure Pollutant concentration X exposure duration (or it is directly
measured by integrated sampling)
Dose Exposure 1) x dosimetry factors (absorption rate, inhalation
rate, etc.) divided with body weight or surface area
Lifetime individual risk Dose (2) >< risk characterization factor (carcinogenic potency,
noncarcinogenic threshold, e.g., NOEL) or severity (e.g.,
NOAEL), with uncertainty factors
Risk to exposed population Individual risk )3( X number in exposed population (this should
take into consideration age, and other susceptibility factors,
population activities, etc.)
cording to the health effects of concern. For carcinogenic effects, the total time
(hours or days) of exposttre during a person's lifetime is the principal concern (cx-
posure every day over a lifetime would be 25,550 days, assuming a 70-year life-
time). For noncarcinogenic effects, short-term exposures at elevated concentrations
are targeted, therefore a duration of hours or even minutes may he important. For
chronic exposure, an average daily pollutant concentration is usually used with
the assumption that it is relatively constant over a lifetime. For children, epore
periods are generally divided into age categories, e.g., 0-6 months, 6 months to 5
years, and 5 years to 12 years, because of their differing body weights.
The second equation combines the exposure information with dosimetry fac-
tors in a simple model to estimate the average dose per day over a lifetime. These
factors include absorbed rate, average body weight, average lifetime, and others,
as relevant. Dose is usually expressed as pollutant mass per kilogram of body
weight per day. It should also include exposures from all media (air, water, soil,
direct skin contact, etc.), such that the total dose is the sum of all of the indi-
vidual doses.
The third equation integrates this exposure assessment with the dose—response
relationship. As discussed in the section Relationship Between Dose and Health
Outcome, it incorporates uncertainty factors (and any other modifying factors
that reflect professional judgment regarding scientific uncertainties of the entire
database) with the NOAEL. This creates a benchmark against which to evaluate
the significance of the dose with respect to its implication for health. The U.S.
EPA has estimated potency factors that can be applied for many carcinogens.
(Methodologies to estimate the chance of toxic outcomes other than cancer are
less developed.) The reference dose, or recommended maximum concentration in some
jurisdictions, is the NOAEL divided by the uncertainty factors multiplied by any
modifying factors of concern. The lifetime individual risk is therefore the prod-
uct of the dose multiplied by these response factors. For cancer, this is expressed
as the lifetime excess risk of cancer for an individual exposed at the given life-
time exposure. For noncarcinogenic agents, it is usually assumed that there is a
threshold below which there is no effect. The ratio of the exposure level to the
estimated threshold dose gives some indication of the likelihocd that adverse
health effects will result from exposure to the toxic substance.

To generalize these average exposures and risks to the individual to an en-
tire exposed population (consisting of many individuals, who may be very dif-
ferent from one another), one multiplies the estimate of average or worst life-
time individual risk by the number of individuals in the population (or each
subpopulation) exposed. This final figure is the excess risk for a given effect that
an exposure produces for an entire population. How this risk should then be in-
terpreted and communicated to the public and the approach used to manage this
risk will be discussed further in Chapter 4. First, though, an example is provided
of how the above principles can be applied in field studies.
Specific Health Risk Assessments in Field Situations

When risk assessment framework is applied to a new field situation, new or un-
expected problems and pitfalls inevitably occur. In some cases it is obvious what
risk factors are involved. In others the potential hazards is extremely difficult to
recognize. In still other situations the ingested dose may be easily calculated from
food contamination levels and average consumption data. In others the situation
is very complicated because many different exposure routes are involved and
dosimetry factors are not available, in such cases, the use of biomarkers may be
the only effective way to come to an acceptably accurate estimate of the total
dose.
HEALTH_IN ENVIRONMENTAL IMPACT ASSESSMENT___

Health risk assessment may also be used to anticipate the potential health effects
of projects or activities planned for the future. During the formulation of devel-
opment policies and the planning of projects, health effects often receive inade-
quate attention. In many countries where there are requirements and the ca-
pacity in place to assess environmental impact, only (or predominantly) impacts
on the biophysical environment are assessed routinely. When expected envi-
ronmental effects of pollution or ecosystem disturbance still conform to the legally
established environmental standards, routinely it is then assumed that adverse
human health effects are not likely to occur. This assumption is based on the
idea that adverse human health effects are always adequately presented by stan-
dards designed to proteci the environment.
Methods have been developed to identify, assess, and mitigate the environ-
mental and health effects of major industrial, agricultural, and other large devel-
opmental projects before they occur. Guidelines on environmental health impact as-
sessments (EHIA) have been prepared by several international organizations,
including the WHO's regional office for Europe (WHO, 1985, 1986). Several coun-
tries have also prepared national guidelines. With the declaration adopted at the
1992 UN Conference on Environment and Development that "human beings were
at the centre of concern for sustainable development," it is now widely acknowl-
edged that environmental impact assessments must address health concerns.
In principle, the assessment of adverse health effects follows an approach sim-
ilar to the risk assessment framework discussed in the previous sections of this
chapter. First, potential hazards associated with the project that require further
investigation have to be identified. Subsequently, emissions have to be calculated
RISK ASSESSMENT 139

or estimated using technological specifications of the project. From these data,
emission concentrations, exposure, and total dose should be calculated with
mathematical models that have been developed specifically for these purposes
and that take local geographical characteristics and climate factors into account.
(The interpretation of the generated data requires specific skills and expert judg-
ments. It may not be easy to determine the importance of, for instance, a 10
dB(A) increase in noise levels for the inhabitants of a particular residential area).
The relative importance of some impacts in comparison with other impacts may
also have to be considered. Finally, health risks can be characterized as discussed
in Table 3.10. At this stage, it should be realized that certain projects may change
the nature and demographics of the exposed population and the percentage of
vulnerable persons. For example, large projects invilving resettlement of popu-
lations will increase the percentage of elderly people amcng the exposed popu-
lation simply because older individuals are more reluctant to move. Large con-
struction projects, in contrast, may increase the number of young male adults.
Since an environmental impact assessment (EIA) is a practical process, it is not
generally possible to await results from new research. Consequently, conclusions
must generally be based on currently accepted scientific knowledge, while si-
multaneously cind ucting research to evaluate future environmental impacts.
Usually the only actual measurements that can be performed during the prepa-
ration stage of a project and the baseline assessments or measurements taken
from pilot projects. Extrapolation of data regarding emissions, exposures, and (if
available) health effects from similar projects can be extremely useful. Extrapo-
lation from one situation to another situation where there are different geo-
graphical and demographic features as well as exposure characteristics usually
requires a number of assumptions, and specific expertise.
The health component of environmental impact assessments should incorpo-
rate more than the best scientific information available. It should draw upon
community-based information and traditional knowledge of native peoples and
others in the community. It should also recognize that many projects have ben-
eficial as well as adverse effects on health and well-being. By creating jobs and
providing other economic benefits that contribute to a better standard of living,
health may be greatly improved because of the project in question. As noted in
Chapter 1, economic well-being has been repeatedly linked with longevity and
other indicators of health, because, among other reasons, people with adequate
income can afford to eat balanced diets and live healthy lifestyles. Adverse ef-
fects on health may be disproportionately experienced by people who do not
share in a project's benefits. Thus the health component of the EIA should as-
sess who will benefit and who may experience adverse effects. If potential ad-
verse effects are identified, recommendations for mitigation and follow-up mea-
sures should be included in the environmental impact statement (hIS) that the
project's proponent is required to do. The FIAs may also contain alternatives to
the project, including the potential effects on health of not allowing the project
to proceed. Although there may be jurisdictional considerations regarding which
government department is responsible for occupational versus public health in
some countries, both components are essential to ascertain the potential bene-
fits and adverse effects of a proposal.

BOX 3.6
The Lower Seyhan Irrigation Project in Turkey
One of the greatest water-related projects in Turkey, known as the Lower Seyhan
trrigation Project, was started in the Cukurova regicn in the early 1950s. The ac-
tivities in the project included the construction of a dam on the Seyhan river to
store water for hydroelectric and agricultural purposes; the establishment of a spill-
way for excess water; construction of irrigation canals to distribute the water
throughout the plain and for irrigation of fields; and construction of drainage canals
for excess water from the fields.
The Cukurova authorities did not consider it a danger when malaria-infected
workers arrived from the southeastern part of Turkey (where malaria transmission
still occurred). It was thought that the disease was totally under control because of
the very Imv number of malaria cases reported from the entire country. The con-
sequences of the project can be listed as follows:
I. Populations from areas to be covered by water were resettled around newly ir-
rigated areas.
Productivity of irrigated lands increased.
Insects and different kinds of insecticides were introduced into the area, creat-
ing vector resistence to insecticides.
Irrigation expanded the number of arabic fields, creating an increase in the need
for laborers.
People moved from poorer parts of the country (most of them came from ar-
eas where unnoticed malaria epidemics still occurred) to he seasonal workers
in the newly developing areas.
Seasonal workers settled along the canals (attracted by vegetation and slopes of
less than t%), where water collections became efficient breeding places for
malaria vectors.
Malaria parasites were introduced to the local mosquito vector (An satharovi),
which has a great capacity for transmitting the disease.
S. Industries increased their work on local products because of the agricultural de-
velopment.
The increase in industrial activity created increased demand for workers.
Workers and families gravitated toward industrial activities, resulting in an in-
crease in the population of the Ctikurova region.
if. Unhealthy settlements were established around towns for the incoming popu-
lation.
New, high-rise apartment buildings were built to meet the housing needs of the
newcomers. The underground floors of these buildings became new breeding
places for vectors because of the high level of the water table and deep base-
ment excavation.
Malaria parasites were transmitted to nonimmune local people.
Finally, there was a resurgence of malaria in the area. During 1970, the num-
ber of cases reported in the Cukurova region increased from 49 to 149.
Source: WHO/CEMP, 1992.
RISK ASSESSMENT 141

Multidisciplinary collaboration is crucial in an EIA. It is important to ensure
that the health components at each stage of the assessment are adequately ad-
dressed. To be effective, the EtA should occur at the project planning stage. It
must be an integral component in the design of a project, rather than something
added on after the design is completed. In this way the HA may suggest alter -
native project designs with greater health benefits and fewer health risks. For
any large project, some description of the baseline environmental health and so-
cial conditions is essential. This should include the demographic characteristics
of the potentially affected populations, the current health status, the local health
care and occupational health services, the characteristics of any incoming groups
of people, such as construction workers or miners, the history of the potentially
affected populations in relation to development, and any traditional behaviors
that may be impacted by the development. An irrigation project in Turkey (de-
scribed in Box 3.6) illustrates how one project can influence a community's health
through various mechanisms.
Increasing public awareness of technological and environmental health risks
has been accompanied by increasing public participation in the decision-making
framework. As a result, public involvement should be an integral part of any EIA
process. Following are advantages of including the general public and other in-
terest groups in the EIA:
• greater awareness of the environmental issues important to the public

• possible identilication of alternative actions
• an increase in the acceptability of the project, as the public will better under-
stand the reasons and risks related to the project
• minimizing of conflict and delay
ucstions
I. Consider all information that is needed to assess human exposure to a spe-
cific hazard. Consider how this information could be gathered.
What are the advantages and disadvantages of environmental and biolog-
ical monitoring?
Which of the consequences indicated in Box 3.6 are directly or indirectly
related to health? Which of these impacts on human health can be expected to
be positive or negative? Which of these aspects would have to be taken into ac-
count in an EHIA, and what specific information would be needed to assess quan-
titative health risks prior to the onset of the project? What would be needed to
assess quantitative health risks prior to the onset of the project?

RISK MANAGEMENT
LEARNING OBJECTIVES

• discusss the principles of risk management, including the process for the
selection, implementation, and evaluation of appropriate control strate-
gies
• identify the factors affecting risk perception and the principles of risk com-
munication and be able to take these into consideration in risk manage-
ment
• discuss the advantages and disadvantages of controlling pollutants at each
stage: at the source, along the path (the environment), and at the level of
the person
• describe the basic requirements of a surveillance system
• outline the approach to managing an environmental emergency
• apply the principles of economic evaluation of environmental health in-
terventions
CHAPTER CONTENTS
The Approach to Managing Risk Control at the Level of the

Risk Evaluation Target/Person
Comparing Risks to Standards or Health Education as a Risk
Guidelines Management Tool
Comparing Risks When There are Risk Monitoring and Use of Indicators
no Historical Data Health Surveillance Systems
Factors Affecting the Perception and Environmental Health Indicators
Acceptance of Risk Special Problems in Managing
Risk Perception Environmental Health Risks
Coping Strategies Approach to Environmental Health
Principles of Risk Communication Concerns of Individuals
Prevention and Control of Exposure to Managing an Environmental
Environmental Hazards Healih Emergency
Framework for Approaching Cost-Effectiveness and Cost-Benefit
Control Strategies Analysis of Interventions
Control at the Source Case Study: The Value of Reducing
Control Along the Path Residential Radon Exposure in
Canada
143
THE APPROACH TO MANAGTNG RISK
Risk management brings together the evaluation and perception of risk to con-
trol exposure to hazards (Fig. 4.1). It is partly a scientific, quantitative exercise
in which the results of a risk assessment (Chapter 3) are compared to standards,
guidelines, or comparable risks. Having made this comparison, and knowing the
assumptions, extrapolations, and estimates that go into the two numbers in the
comparison (as discussed in Chapter 3), an environmental health professional
can determine whether a significant risk is present. But the perception of the risk
by the individuals or community facing the risk must also be taken into account.
Of course, the manner in which the risk evaluation is communicated will also
affect risk perception, as will the effectiveness of communicating the plans for
and results of exposure control.
After the risk is evaluated and the exposure is controlled as appropriate, the
risk must be monitored to ensure that it remains under control. Although some-
times the problem can be solved, usually the process is an iterative one in which
the risk must be reassessed and community perception reevaluated on a contin-
ual basis. In reality, this interactive process means that the different steps in risk
assessment and management may be carried out simultaneously.
jcj< FVALUATION
Comparing Risks to Standards or Guith 'ines

A health risk may range from minor physiological changes to premature death
(see Table 3.5). What is understood to be an important or unacceptable level of
risk depends in large part on the concept of health accepted in the community
in question. For example, in setting most environmental and occupational stan-
dards in North America, authorities have assumed that there is no threat to health
as long as the exposure does not induce disturbance of a kind and degree that
overloads the normal protective mechanism of the body. In the former Soviet
Union, in contrast, maximum permissible concentrations for environmental poi-
lutants were set below the level that causes physiological and other changes of
uncertain significance. These standards had the status of guidelines rather than
absolute limits, and were not necessarily enforced.
In some jurisdictions guidelines are established, which cannot be enforced by
law, while in others, standards are set, and individuals or companies that exceed
Risk Assessment
Hazard identification
Dose-response assessment
Exposure assessment
+ Risk Management
00 5. Risk evaluation
Risk Characterization 6. Risk perception and communication
Control of exposure
Risk Monitoring
Figure 4.1 Risk assessment and management framework.

the standards may suffer the penalties prescribcd by legislation. In either case,
the general approach for evaluating risk is to compare the estimated exposure to
that which is considered acceptable, based on guidance values or standards (e.g.,
the acceptable daily intakes [ADI5] or risk-specific doses [RsDs] that were calcu-
lated in Chapter 3).
The purpose of any risk management effort is to help make decisions to con-
trol hazards. While comparison with administratively established standards or
guidelines (e.g., ADIs or RsDs) is essential for inspectors and other enforcement
officials, it is important for environmental health professionals to gain some per-
spective on the magnitude of the risk and to he able to convey its meaning to
decision makers and to the public. The way in which risks are perceived relates
strongly to the manner in which they have been estimated. Risks calculated from
historical data tend to be easier to understand. For example, there are plenty of
data on automobile accidents, and any risk in one jurisdiction can be compared
with data from another (with certain methodological limitations). Data on a given
risk in a given jurisdiction can also be compared with data from the same juris-
diction at an earlier date.
However, this historical approach to estimating risks is only applicable in sit-
uations in which the hazards causing the risks are known and exposure to them
is predictable and the outcomes resulting from exposure can be directly mea-
sured in a population and related back to exposure to the hazard. For example,
if the aim is to calculate the risk of cancer arising from exposure to cigarette
smoke, one would need to know that smoking rates rarely change dramatically
from year to year, that smoking a certain amount is associated with a certain
level of risk, and that the numbers of people in the population of concern who
smoke at various levels can be specified. This calculation can be done only be-
cause cancer cases can be identified and counted in the population and it is al-
ready well known that cigarette smoking causes cancer.
Comparing Risks When There Are No Historical Data

If there is no historical database for a hazard, so that dose—response information
does not exist, the evaluation of the risk is much more complicated. With respect
to new technology for which there is no historical database (e.g., a new power
plant or industrial facility), one approach is to consider it in separate parts, cal-
culating the risks from each part and adding them together to estimate a risk for
the whole. In this approach all possible chains of events from an initiator to a fi-
nal accident are followed in what is referred to as an et'ent tree, with the proba-
bility of each event in the tree being estimated from historical data in different
situations.
It is particularly helpful to compare risks that are calculated in a similar man-
ner. For example, the risk of traveling by automobile can be compared to trav-
eling by horse or by airplane. Similarly, radiation risk from a medical X-ray can
be compared to that of radon gas, to the dose an average resident experienced
near Chernobyl, or to the natural radiation dose an individual receives on a long-
distance trip by air.
Setting standards regarding water quality, food contamination, and air pollu-
tion is discussed in chapters addressing air, water, and food (Chapters 5, 6, and
RISK MANAGEMENT 145

7). Threshold limit values used in occupational health will be discussed further
in the chapter on industry (Chapter 10).
FACTORS AFFECTING THE PERCEPTION AND

ACCEPTANCE OF RISK
Risk Perception
Environmental health professionals often disccvcr that the public perception of
an environmental health risk differs widely from that of scientists. The level of
public outrage toward an environmental health hazard plays a major role in the
acceptability of the risk associated with this hazard. In past decades, it was often
thought that if the public were educated about the risks associated with the haz-
ard, people would find the hazard more acceptable. It is now known that un-
derstanding the risk is only one of many dimensions that affect risk perception
and acceptance. Moreover, this has been shown to be a fairly minor factor rela-
tive to other dimensions. Some of the more important dimensions that affect en-
vironmental health risk perception and the strategies for risk management and
communication in light of these dimensions are shown in Table 4.1. Aside from
these (e.g. voluntarism, attribute of blame, understanding), risks that have de-
layed health effects and those that affect future generations are accepted less
readily than those that are immediately apparent.
Coping Strategies
Many factors influence how people respond to environmental health risks. As dis-
cussed above, one person's perception of a risk may be completely different from
another person's perception. In addition, individuals have different coping strategies
to deal with perceived risk, or stress in general. A distinction can be made between
coping strategies that concentrate on either the individual emotional response, called
emotion-focused coping, or eliminating or reducing the observed hazard, problem-focused
coping. These strategies may involve both direct action and mental processes.
Most of this text addresses problem-focused responses to risks. Viewing an indi-
vidual's health problems in terms of emotion-focused coping may lead the environ-
mental health professional to attribute them to the emotional stress of a situation
(e.g., Chernobyl; see Chapter 9) or to the person's own actions, inability to cope, or
other personal characteristics. This may inadvertently lead to victim blaming, which
in turn may obscure the real threat that a risk imposes and in any case does not help
the professional address the individual in an effective manner. Nonetheless, it is im-
portant for environmental health professionals to have some understanding of cop-
ing strategies to manage environmental health risks appropriately.
Cognitive coping strategies are characterized by the use of thought processes
aimed at the reduction of experienced stress. These mental strategies take many
different forms:
Problem denial. The individual tries to convince himself or herself that the health
risk is exaggerated by others or by the media, and that the authorities will ex-
ercise their responsibility to protect the community.

Problem amplification. The individual perceives the problem as much larger than
it is, usually because of the stress in their lives.
Problem suppression. The individual does not deny the perceived risk, but just tries
not to think about it.
Problem redefinition. The individual redefines the problem in such a way that the
positive effects (e.g., stimulation of the regional economy, or increased employ -
ment) are more important.
Problem acceptance. This strategy aims at regaining emotional stability in a situa-
tion in which the individual sees no possibilities to influence change.
Coping strategies may lead to direct action-based strategies. These include the
following:
Action aimed at risk reduction. This could be achieved by trying to influence the
decision-making process, for example by demonstrating against a given situation
or organizing action groups.
Searching for information. This could result in a better understanding of the risk
and may be a valuable strategy since unfamiliarity usually relates to overesti-
mation of the risk.
Searching for help. This would include contacting environmental action groups that
can give advice or practical assistance in reducing the risk. Working oil one's feel-
ings in discussion groups is another active form of coping.
Active search for distraction. Immersing oneself in sports, hobbies, or other activi-
ties and avoiding thinking about the problem would characterize this type of ac-
tion.
Emotional modification. Use of tobacco, alcohol, or drugs can be seen as a form of
emotional modification. These coping strategies, however, involve exposure to
health hazards and may result in disrupted social structures, violence, and crim-
inal behavior.
Apart from coping strategies, it is likely that an individual's personality and

degree of social support will influence the stress response. Evidence indicates that
both the health and well-being of individuals with more social support are gen-
erally higher than for those individuals without this support. This social support
may consist of actual assistance or information provided to resolve problems, or
it may include emotional support. Personality characteristics that have been as-
sociated with lower stress responses include a general attitude of trying to influ-
ence important events in life; a tendency to define sudden changes or threaten-
ing situations as a challenge rather than a threat; motivation of being involved
in society and having a purpose in life.
Principles of Risk Communication

Risk communication is defined as the purposeful exchange of information about
the existence, nature, form, severity, or acceptability of risks. The objectives of
risk communication could be either (a) to alert the public or decision makers to
RISK MANAGEMENT 147

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TABLE 4.2
THE U.S. ENVIRONMENTAL PROTECTION AGENCY'S
SEVEN CARDINAL RULES OF RISK COMMUNICATION
Accept and involve the public as a lcgitiniatc partner.
Plan carefully and evaluate your efforts.
Listen to the public's specific concerns.
Be honest, frank, and open.
Coordinate and collaborate with other credible sources.
Meet the needs of the media.
Speak clearly and with compassion.
Source; Covello and Allen, 1988.
a significant risk of which they may be unaware, or (b) to calm concerns about
a small risk that the public or decision makers perceive as serious.
With increased public concern over various environmental health risks, in-
creasing demands are placed on environmental health professionals to provide
information that explains the nature of risk in clear, comprehensible terms and
that conveys credibility and trustworthiness. Increasing attention has been paid
to risk communication to respond not only to the publics desire to be informed
but also to the need to overcome opposition to decisions and to develop effec-
tive alternatives to direct regulatory control. Such alternatives can require greater
accountability on the part of individuals, agencies, or private corporations.
It must be stressed that merely disseminating information without relying on
communication principles can lead to ineffective messages regarding risk and in-
advertantly convey ineffective control of a hazard. The U.S. Environmental Pro-
tection Agency (EPA) has articulated seven cardinal rules of risk communication
(Table 4.2) to prevent such nuscommunications. In addition to these rules, it
must be emphasized that to provide effective risk communication, the health pro-
fessional must understand the appropriate technical information that may arise.
Because in some countries the public obtains much of the environmental health
risk information from the news media, the guidelines for dealing with the me-
dia in Box 4.1 are wcrth considering.
PREVENTION AND CONTROL OF EXPOSURE

TO ENVTRONMENTAL HAZARDS
Framework for Approach ing Control Strategies

An essential step in risk management (Fig. 4.1) is the prevention and control of
exposures to environmental hazards. In the classic occupational hygiene model of
controlling a hazard (as discussed in any industrial hygiene textbook), the ideal sit-
uation is to prevent such exposures altogether; this model is known as control at
the source. Here substitution or enclosure of the hazard as well as other means of
control are used. If this cannot be achieved, exposure should be reduced along the
path—through ventilation, protective barriers, or related measures. As a last resort,
exposure should be controlled at the level of the person, by means of personal pro-
tective equipment, administrative controls, or other primary prevention measures,

R(")X4.1
Tips for Dealing with the Media
I. Don't take the questions personally. If you sound defensive the media will pick
that up and push to find out "what you are hiding."
Never say "no comment." This is often interpreted by journalists as an admission
of guilt. Instead, say why you are unable to comment (e.g., "We are currently in-
vestigating the situation and are unable to comment on our findings at this time").
Always tell the truth. If there is a problem for which you share in the responsi-
bility (e.g., errors in judgement were made), explain it, but remember to list
many positive aspects so that the negative ones will be outweighed (e.g., "We
initially had difficulty with our communication procedures, but they have since
been corrected and following this tire, the entire emergency plan will be reviewed
and improved").
Never speculate. Only comment on the facts; the rest is "under investigation,"
"unconfirmed," or "not known."
Don't speak off the record. Unless you have good reasons to believe you can trust
the journalist to honor an agreement to allow you to speak off the record, you should
consider any comments you make to be fair game in the pursuit of a good story.
OTHER GENERAL TIPS

• Return calls from the media as soon as possible. This gives journalists time to di-
gest the information you give them and build their stories around it, instead of
adding it in after most of the story has already been written.
• Come to the interview with two or three key points that you want the journal-
ist to present to the public. Repeat the points several times.
• Assume the journalist has no background in the subject—explain everything.
• Avoid jargon (otherwise they will simplify things for you—possibly incorrectly).
• Come prepared with a written summary of risk information (e.g., outcome dis-
eases, factors, rates, confounders, standards, and guidelines).
• Stay within the lintits of your expertise. Refer to others when indicated.
• Do not say more than you want to.
• Do not comment on facts or figures you haven't seen.
• If you don't know, indicate that you warn to verify the facts and will get back to
them with the information.
• If the questions are becoming repetitive, the health specialist can end the inter-
view by saying "I think we have covered everything. Why don't you call me later
if any new questions that occur to you."
• If a reporter is bullying you, remain calm. Asking to have the question repeated
gives you time to control the urge to get angry.
• II you are misquoted you have to weigh your injured pride against having the
whole issue rehashed. It may he best to just phone the reporter and explain the
error. (You may consider sending a polite letter to the reporter so that you have
documentation of the corrected version for possible legal purposes.)
• Fight the journalist's tendency to dichotomize risk (i.e., risky? yes/no). Do your
best to have theiri understand the grade of risk.
• At the conclusion of the interview, feel free to ask the journalist about his or her
understanding of the issue and what parts of the information you have provided
will be used. While journalists are under no obligation to reveal these things, they
often will cooperate and it may provide an opportunity to clear up a misunder-
standing before it ends up in print.
TABLE 4.3
HIERARCHY OF INDUSTRIAL CONTROLS
Stages
CONTROL AT THE SOURCE
Substitution
Engineering controls
General ventilation
CONTROL ALONG THE PATH
Exhaust ventilation
Protective harriers
CONTROL AT THE LEVEL OF THE PERSON
Personal protective equipment

Training
Administrative controls (e.g., shift rotation)
SECONDARY PREVENTION
such as training, or even biological measures, such as immunization. The final inca-
sure of controlling a hazard is secondaiy prevention, i.e., early detection of effects of
exposure and subsequent remediation. The hierarchy of methods for controlling a
hazard is shown in Table 4.3. The same hierarchy of controls can also he used in
environmental health hazard control and in setting standards (Fig. 4.2).
THE SOURCE THE ENVIRONMENT THE TARGET
Product Product
standards quality
control Biological
standards
Residue
Product Pro3 I Transformation standards
in tissue
Metabolism
Environmental quality
Emission goals and standards
control Interior
Absorption
Source Emission Dispersion
Process Emission 'Sink'

standards standards
Surface
Exposure
(primary Excretion
protection)
standard
Figure 4.2 Pollutant pathway showing possible points at which standards may be set. From
de Koning, 1987, with permission.

It should be noted that control actions may be taken at more than one point.
When making decisions regarding the points of intervention and the type or level
of control to be used one must take into account the chemical and physical char-
acteristics of the hazard, its transport through the environment, and possible con-
comitant exposures. Other considerations may include the technology available,
the financial resources of both the industry and the government that must en-
force the decisions, as well as the legal and cultural traditions of the jurisdictions.
Control at the Source

A hazard may be controlled at the source by eliminating it entirely or by using
innovative engineering means to eliminate or minimize exposure to the hazard.
A common method of controlling exposures that are not very toxic is general ven-
tilation (or dilution ventilation) of indoor air, through which large amounts of air
arc introduced into a workplace (or other hazardous environments) by either
natural means, such as opening doors and windows, or the use of fans to move
large amounts of air. Rather than removing the contaminants, general ventila-
tion dilutes them in a large volume of air to reach an acceptable concentration
of the contaminant. As shown in Figure 4.2, control at the source may be regu-
lated by product standards, process standards, or emission standards.
Product Standards If a substance does not have a known threshold level or has
not been adequately tested, it may make sense to redesign the product to mini-
mize the amount of the substance required, or search for a substitute. Govern-
ments can ban the use of a substance for specific purposes. Sweden, for exam-
ple, banned the use of cadmium except in electroplating, pigments, and stabilizers
for plastics (and soldering if the product does not come into contact with drink-
ing water or food). Governments may also encourage the use of substitutes by
imposing strict labeling requirements.
Process Standards If a pollutant enters the environment during a manufacturing

process, governments can encourage the use of other processes for manufacture,
through such measures as tax incentives or information exchange programs; leg-
islation is another option. In Japan, for example, the outbreak of Minamata dis-
ease prompted the government to require the recycling of all water containing
mercury and the replacement of mercury catalysts with other technology.
Emission Standards Emission limits on industrial discharges to air and water, and
more recently to soil, have been in place for decades in many jurisdictions. These
standards may be expressed in terms of the permissible concentration of a pollutant
in units of air emitted or wastewater discharged by a source or in terms of a total
load of pollutant per time, unit of production, or unit of energy or materials input.
Emission or effluent standards may also be expressed in terms of danger to health
or the environment, with a preferred method of control being specified. In this ap-
proach, the best available and economically feasible control technology is used.
Standards can also relate to operating practices, including maintenance mea-
sures to avoid spills, and measures to promote prompt clean-up, careful storage,
and segregation of wastes. They may stipulate rules for cleaning and maintenance
RISK MANAGEMENT 153

of equipment as well as training. Emergency measures may also be required.
Many jurisdictions do, in fact, have regulations concerning the packaging, stor-
age, handling, transportation, and disposal of toxic substances.
Control Along the Path
An environmental quality standard (Fig. 4.2) may range from a guideline value
designed to provide a degree of health protection, to a regulatory standard with
specifications of permissible concentrations of the contaminant, compliance re-
quirements, prescribed sampling method and frequency, and acceptable analyt-
ical methods. Calculating acceptable daily intakes (ADIs) for drinking water was
discussed in Chapter 3, and the development of threshold limit values (TLV5) will
be discussed in Chapter 10.
For chemical hazards, local exhaust ventilation is an example of a control that
is along the path between the source and the target. Through local exhaust ven-
tilation, airborne contaminants are captured at or near the place where they are
generated and removed from the workplace. For some exposures, for example,
fumes and gases produced by welding, local exhaust ventilation is much more
effective than general ventilation. It is also more economical, as it requires less
air to be moved. A local exhaust system usually includes a hood or enclosure,
ductwork, an air-cleaning device, and an exhaust fan to draw the contaminated
air through the exhaust system and discharge it to the outside. The system must
be designed to capture the contaminants before they reach the breathing zone
of the workers. Overhead hoods should not be used if their design draws the
contaminants through, instead of away from, the workers. Figure 4.3 shows three
examples of local exhaust ventilation for welding operations.
For physical hazards such as noise, barriers can be effective, as are acoustic
treatment of walls, ceilings, and floor, and increasing the distance between the
source and receiver.
Control at the Level of the Target/Person
Particularly in occupational settings, control at the level of the person may also
be regulated (the "target"; see Fig. 4.3). Administrative controls, which involve re-
ducing the number of exposed workers and the duration of exposure, are fraught
with controversy. Clearly, only those workers needed for a job should be in an
area that is hazardous. Maintenance workers, electricians, cleaners, or other
workers should do their job when the hazardous prccess is not in operation.
Maintenance workers may be more highly exposed to hazards than operational
workers since procedures are often not developed for their protection and their
work often requires close proximity to hazardous plant processes. Thus, special
provisions for the protection of maintenance workers must be included in chem-
ical safety procedures. Although a reduction in the length of time or the fre-
quency of exposure of workers may be achieved by a system of job rotation, it
is not acceptable to simply expose more workers less often to unacceptably high
levels as an alternative to reducing exposure levels.
Personal protective equipment (PPE) should be used only after substitution and
engineering controls have been fully considered and have been implemented as
much as is feasible. Personal protective equipment includes face masks, respira-

Freely suspended open hood with flexible duct
Position the hood Fixed exhaust hood at welding bench

as close as possible
to the source of fumes
Exhaust duct
Exhaust hood
Baffles to improve
efficiency
Welding gun mounted on exhaust hood
Welding
rod
Shielding
gas inlet
duct
Exhaust -
outlet duct
Work
Exhaust flow requirements must be
determined for each welding operation
and welding gun configuration by
experimental testing with air contaminant
sampling and analysis
Figure 4.3 Examples of local exhaust ventilation for welding. Source: Fact Sheet From
1-lamilton, Ontario, with permission. Canadian Center for Occupational Health and Safety
(CCOHS).
tors, gloves, rubber boots, protective clothing, goggles and safety glasses, hard
hats, and hearing protection. Table 4.4 summarizes the steps and resources re-
quired for a PPE program. Figure 4.4 shows a uranium miner with PPE and mon-
itoring equipment. The International Program on Chemical Safety (IPCS) has pro-
vided guidelines for using PPE and for choosing the proper equipment (see How
to Use the IPCS Health and Safety Guides, UNEP/ILO/WHO, 1993).
Other measures at the level of the target or exposed individual include im-
munization against infectious hazards. Guidelines regarding which workers
RISK MANAGEMENT 155

TABLE 4.4
CHECKLIST FOR PERSONAL PROTECTIVE EQUIPMENT

PROGRAMS
Correct equipment
Thorough trausing program
Fit lest
Regular equipment maintenance
Secure and clean place of storage for each individual's Set of
equipment
should receive which immunizations are provided by various international agen-

cies and associations. When carrying out such a program it is important to con-
sider several issues, such as whether immunizations should be made mandatory
or voluntary, what risks are involved, what the implications are for the individ-
ual when immunity fails to develop, or what the conscquences are of develop-
ment of the disease in question.
Health Education as a Risk Management Tool
Many health risks have a behavioral component. For instance, in an occupational
setting, protective clothing can be provided that gives adequate protection against
exposure but that is not comfortable to work in, thus employees may not want
to wear them at all times during working hours. Furthermore, safety guidelines
or procedures may not be followed for various reasons, e.g., they are time con-
suming or considered to be redundant.
When it became generally accepted that diseases should be prevented rather
than cured, the importance of health education in the promotion of public health
also became obvious. There are a number of instruments that can be used to ed-
ucate the public, including TV spots, billboards, and local meetings. A frequently
occurring misconception, howevcr, is that the transfer of knowledge and rele-
vant information to the population of interest alone will result in behavioral
change. To achieve a lasting behavioral change, a number of crucial steps have
to he taken:
Problem analysis: characterizing the relationship between the health problem and
human behavior.
Behavior determinants: identifying the factors that determine specific behaviors.
Options for changing behavior. assessing the relative importance of such determi-
nants and the extent to which they can be changed
Intervention plan: determining how behavior can be changed most successfully
Intervention implementation: carrying out the intervention to change behavior
Evaluation: ascertaining the effect of the intervention.
When the relationship between the health problem and human behavior is not
well established, or when behavior is only of minor influence on the extent of
the problem, an intervention plan for changing behavior is not likely to improve
public health significantly.

p cord
Fold-dov Lrd hat
earmutt
Miners I
lasses
Ear plug
badge
Gloves stripes
i meter
ty belt
Radio
Radon /
pump
Ref lecti battery
)veralls
boots
?quired
Figure 4.4 Miner with PPE and personal monitoring equipment. From Carneco, 1996,
with permission.
The most important types of determinants of behavior include attitude, social

influences, perceived behavioral control, skills, and barriers (see Box 4.2 and Fig.
4.5). When trying to change specific behavioral elements, it is essential to un-
derstand the reasons behind the undesired behavior. An individual may intend
to show the desired behavior but is simply not capable of doing so. For exam-
ple, someone may want to reduce exposure to organic solvents from paint by us-
ing water-based paints, but cannot achieve this goal for various reasons: these
RISK MANAGEMENT 157

BOX 4.2
A Theory of Planned Behavior
The main determinants of behavior according to the theory of planned behavior

(Ajzen, 1991) are indicated in Figure 4.4. In this model, intentions are assumed to
capture the motivational factors that determine the behavior and indicate how hard
people are willing to perform the behavior under consideration. The first determinant
of an intention is attitude, which refers to the degree to which an individual has a fa-
vorable or unfavorable evaluation of the behavior. The second determinant refers to
the perceived social pressure to perform or renounce the behavior. Perceived behav-
ioral control is indicated as the third predictor. This factor refers to the perceived dif-
ficulty or ease of performing the behavior and is assumed to reflect past experience
as well as anticipated impediments and obstacles. However, a strong intention to en-
gage in a behavior does not necessarily imply that one is successful in performing it.
Nonmotivational factors such as the availability of resources (money, cooperation,
skills) or opportunities determine people's actual control over their behavior.
Attitude
Skills
Background variables Social influence Intention Behaviour
Perceived behavioural Barriers

control
Figure 4.5 Determinants of behavior. From Ajzen, 1991, with permission,
paints are not available in that town (lack of the alternative option), or they are
too expensive (financial barrier).
Other conceptual models have also been developed to help health promotion
professionals to carry out their duties. One model, which builds upon the
Ottawa Charter's definition of health promotion as activities that enable people
to increase control over the determinants of their health, is known as the
PRECEDE—PROCEED model (Green and Kreuter, 1999). It uses educational ap-
proaches to influence the predisposing factors to unhealthy choices through di-
rect communication, the reinforcing factors through promoting changes in val-
ues that support lifestyle choices, and the enabling factors to permit these changes
through training and organization. While the PRECEDE part of the model ad-
dresses the predisposing, reinforcing and enabling constructs in educational and
ecological diagnosis and evaluation, the PROCEED part addresses the policy, reg-
ulatory, and organizational constructs in educational and environmental devel-
opment. Box 4.3 elaborates on this model and how it relates to the DPSEEA
framework used elsewhere in this text.

BO(4.3
The PRECEDE-PROCEED Model of Health Promotion and
its Relation to the DPSEEA Framework
The figure below illustrates the PRECEDE—PROCEED model (Green and Kreuter, 1999),
indicating that the place to start is to conduct a social assessment in a community, as-
certaining the perspectives of the community members, their hopes, aspirations and
concerns. Next, an epidemiological assessment is conducted to ascertain the health prob-
lems and risk factors. Phase 3 involves identifying the health-related behavioral as well
as physical environmental factors that may he predisposing (e.g., knowledge, attitude,
values of the individuals concerned), reinforcing (e.g., attitude and behavior of deci-
sion-makers) and enabling factors (e.g., availability of resources and skills) underlying
the concerns identified. Phase 4 focuses on assessing the policy and administrative is-
sues that must be addressed, and phases 6 through 9 are the implementation, process
evaluation, impact evaluation, and outcome evaluation steps.
wtm rPffØ Epre Effect
PRECEDE
4 Phase 3 1 Phase 2 Phase 1
Behavioural & Epidemialogical Social
Environmental
aiTeJ Assessment LAssessment AssessI1(J
reuter 1999
shading in
r and dab-
Force -Pres -
•e then cor-
relating to
regulatory,
then corre-
it, whereas
xperts. The
decade or
ming to re-
Jerry Spiegel
RISK MONITORING AND IJSF OF INDI1ATORc
Methods of environmental and exposure monitoring were discussed earlier, as

were the pros and cons of biological monitoring and various methods of health
surveillance. Risk monitoring can be considered a form of auditing the effective-
ness of the combination of risk management approaches used. The variables used
in risk monitoring are often called indicators. Such indicators should be reliable,
easy to measure year after year, closely connected to health risks or measurable
outcomes, and closely related to the opportunity for exposure to environmental
hazards. Also, health outcomes that are used for this purpose should occur within
a short time after exposure. Some indicators that have been prcposed for use in
monit ring environmental health status in populations are the rate of diarrheal
diseases (reflecting water quality), the frequency of asthmatic attacks among in-
dividuals with known asthma (reflecting air quality), the rate of new cases of
leptospirosis (reflecting exposure to rats), the rate of new cases of noise-induced
hearing loss (reflecting exposure to noise in the workplace), and the level of lead
in blood tests of people living in an area (reflecting exposure to lead in the com-
munity).
Some of these indicators, such as diarrheal diseases, are more specifically re-
lated to environmental exposures than others. Asthma rates are not as good in-
dicators as one might expect because the connection with environmental expo-
sure is complicated by many other factors that provoke asthmatic attacks, some
of which, such as allergen exposure, may be more powerful than air pollution
in causing an cffcct. Likewise, cancer rates do not work very well for ongoing
monitoring of exposure to environmental hazards because the effects are delayed
by many years. Indicators that are properly chosen to be informative and prac-
tical in a given situation provide a picture of how the environmental health risks
experienced by a population are changing and how well public health and en-
vironmental measures are controlling the risk. They are also useful for compar -
ing the performance of environmental measures in one country or administra-
tive unit to that in another for setting priorities in controlling risk, or for
demonstrating the presence of a hazard requiring attention.
I-lea lth Surveillance Systems

Periodic health surveillance is conducted by performing a routine standardized set
of tests for the early identification of some (often specific) health problems at reg-
ular intervals, usually annually. it is often applied to workers who are exposed to
a particular hazard to detect occupational disorders early and to prevent them from
getting worse. Use of periodic chest X-rays to identify occupational lung diseases,
such as silicosis and asbestosis, has played a major role in controlling these dis-
eases. Unfortunately, periodic health surveillance alone cannot prevent occupa -
tional diseases and is ineffective for many disorders such as lung cancer and oth-
ers, for which the conditions shown in Box 4.4 are not met. It is important to stress
that screening tests are only part of a surveillance program. To have effective sur-
veillance, the group results must be analyzed and given to the authorities respon-
sible for correcting the problem, and there must be a commitment to act upon
these results. An example of an effective surveillance program is shown in Box

BOX 4.4
Principles to Apply in Choosing Screening Tests for

Surveillance Programs
The test must he sensitive and specific. Sensitivity refers to the proportion of dis-
eased persons in the population who are correctly identified by the test. Speci-
fic/tv refers to the proportion of nondiseased individuals who are correctly iden-
tilied as such by the test. (An insensitive but specific test may yield many
false-negative results (c), whereas a sensitive but nonspecific test may give many
false positives (h(. Note that a posit/ic predictive value refers to the proportion of
persons who have a positive test and are truly diseased. A neqative predictive value
refers to the proportion of persons who have a negative test and are not diseased.
These two indices depend on the sensitivity and specificity of the test and the
prevalence of the disease. They are quoted less often than the sensitivity and
specificity of a test, but should he considered when discussing the usefulness of
a screening test.
The test must he simple and inexpensive.
The test must he safe. The test must have a very high degree of salety as it is
meant to he applied to a large number of normal people who likely have only a
very small risk of the condition in question.
The test must he acceptable. The test cannot be inconvenient, time consuming,
ttncomlortable, or unpleasant to the sttbjects beit1g offered the screening.
Source: Fletcher et al., 1982.
4.5. In this case, only when biological tTH)flitoring for occupational lead poisoning
through centralized reporting of blood lead results was combined with industrial
hygiene controls and enforcement of lead in air criteria did a sustained decrease
in occupational lead poisoning occur (Yassi et al., 1991, 1996).
Environmental Health Indicators

In the process of monitoring risk management, it is particularly important to es-
tablish and use appropriate environmental health indicators. There have been
significant efforts in the international arena to establish a common set of indi-
cators with which to evaluate environmental health policy. For example, experts
catne together for this very prtrpose in March 1993 at The Consultation on En-
vironment and Health Indicators for Use with a Health and Geographic Infor-
mation System (HEGIS) for Europe, where they defined key environmental, So-
cioeconomic, and health indicators for use in the European region. The potential
environmental indicators are shown in Table 4.5. General health descriptors for
which data already exist at a sufficient level of detail and reliability were re-
stricted to measures of mortality and morbidity. Some potential health indicators
considered are shown in Table 4.6 (see Corvalan and Kjellstrom, 1995 or Briggs
et al., 1996, or WRI, 1998 for hill discussion).
RISK MANAGEMENT 161

BOX 4.5
Example of an Effective Occupational Lead Poisoning
Surveillance Program
An analysis was conducted of 16,199 blood lead samples from employees of nine
high-risk workplaces in Manitoba, 1979-94, as part of an integrated regulated oc-
cupational surveillance system. Adjusted median blood lead levels were analyzed,
as was the proportion of levels above the regulatory target over the years. Trends
in individual workers and in each of the targeted firms were also examined.
It was found that a 1979 government regulation specifying the maximum al-
lowable lead in blood as 3.38 Mmol/liter (70 j.rg/dl) was followed by a drop in blood
lead concentrations; the 1983 order to reduce maximum allowable blood lead con-
centrations to below 2.90 mol/liter (60 .rg/dl) was not followed by such a decrease.
Longitudinal analysis by individual worker suggested that companies were comply-
ing by using administrative control—i.e., removing workers to lower-lead areas un-
til blood lead levels had fallen, then returning them to high-lead areas.. In 1987 a
further order was issued that required removal of workers from a site when their
blood lead level was 2.40 j.rrnol/liter (50 ig/dl) and limited environmental expo-
sure to 50 g/m 3 . This new integrated approach succeeded in bringing about a sig-
nificant reduction in blood lead concentrations overall as well as in most of the high-
risk companies. Moreover, this seems to have been accomplished in most companies
without their having to rely on worker rotation.
50
45
40
-J
- 35
-
C)
,?; 30 .- .
-D
25 /N.
Reduce
20 blood Pb to
0
0
15 <70.tgIdL Reduce
blood Pb to Reduce
it. <60pg/dL
blood Pb to
<501.tg/dL
1979 1981 1983 1985 1987 1989 1991 1993

Year
The study concluded that while having an appropriately stringent blood lead tar-
get is essential, focusing upon blood lead as the sole criterion for compliance is in-
effective. Regulations must specifically require environmental monitoring and ex-
posure controls, with biological surveillance serving to ensure effectiveness of these
nteasures. The analysis that was conducted illustrates the usefulness of a compre-
hensive, centralized surveillance system linked to inspections and enforcement, as
it was invaluable in targeting preventive measures and ensuring the effectiveness
of regulatory efforts.
Source: Yassi et al., 1991, 1996.

TABLE 46
POTENTIAL ENVIRONMENTAL INDICATORS FOR HEALTH RISK ASSESSMENT
Substance Indicator and Medium Proxy/Surrogate
AIR QUALITY INDICATORS
SO Concentration in air Exceeding WHO or national

guidelines
Emission
Use of coal for domestic
heating/cooking
NO Concentration in air Exceeding WHO or national
guidelines
Emissions
Use of gas for domestic
heating/cooking
Traffic density
Particulates TSP/PM ( PM Exceeding WHO or national
guidelines
Concentration in air Black smoke
Emissions of TSP
Use of coal
Ozone Concentration in air
CO Conceniranon in air Emissions
Traffic density, city gas usage
WATER QUALITY INDICATORS
Drinking-water Hardness, water color, taste, pH Water treatment

quality Conductivity/TSS
VOC, TOC
Nitrates, nitrites, phosphates
MULTIMEDIA AND OTHER INDICATORS
V005 Concentration of specilic VOCs Emisstons

in air and water Petrol usage
PAHs Concentration of benzo(a)pyrene Small-scale wood and
in air and lood coal burning
Traffic density
Metals and Concentration of Cd, Pb, As, Hg Concentration in air,
trace elements in human tissue water, soil, food
Emissions
Concentration of Al in drinking
water
Persistent organic Concentratiuti of PCB5, dioxin, Concentration in air,
chemicals etc., in human tissue food, water
Emissions
Production/consumption
Pesticides Concentration in food Pesticides use
Concentration in soil, water Sales
Concentration in human tissue Land use
Nitrates Concentration of nitrate, nitrite. Fertilizer usage
phosphate, etc., in surface water Additive use
Concentration in groundwater,
food
Continued)
RISK MANAGEMENT 163

TABLE 4,5
POTENTIAL ENVIRONMENTAL INDICATORS FOR HEALTH RISK ASSESSMENT
(continued)
Substance Indicator and Medium Proxy/Surrogate
Pathogens and Foodhorne pathogens Concentration
allergens Waterborne pathogens Land use/vegetation
Airborne allergens (e.g., pollen) Humidity
Indoor allergens Housing quality
Water treatment
Wastewater treatment
Food hygiene
Radiation Activity of radon in household air Geology
Solar radiation
Radiation equivalent of food Sunshine/cloudiness
Exposure to tobacco Cotinine in urine Particle concentration in
smoke indoor air
Mutagenicity of air
Tobacco consumption
Smoke controls in public
buildings, etc.
Nuisances Nuisance caused by odors Complaints, waste
treatment
Noise levels in home Complaints, noise emissions
Traflic noise Traffic density
PAt-I, potycyctic aromatic hydrocarbons; PCB, polychlorinaicd hiphenyt; ioc, total organic carbon; TSP, total
suspended particulates; TSS, totat suspended solids; VOL. volatile organic compounds.
The linkage between environmental indicators and health indicators is key to ac-
curate monitoring of environmental or occupational health risks (Briggs ef al., 1 996;
Corvalan et al., 1997). To visualize these linkages, Corvalan and Kjellström (1995)
developed the driving force—pressure—state—exposure—effect—action (DPSEEA) frame-
work (Fig. 4.6) as an adaptation of the pressure—state—response (PSR) framework
used by the Organization for Economic Cooperation and Development (OECD) and
the United Nations in the development of indicators for sustainable development
monitoring. The environmental indicators listed in Table 4.5 are primarily state in-
dicators and some of the proxy/surrogate indicators are pressure or driving-force in-
dicators. Figure 4.5 highlights the importance of exposure in environmental health
risk monitoring and the need to include action indicators in monitoring risk man-
agement implementation. A recent example of use of the DPSEEA framework by a
community to assist in developing indicators to evaluate interventions aimed at im-
proving health in an urban ecosystem is provided by Yassi et al. (1999).
SPECIAL PROBLEMS IN MANAGING ENVIRONMENTAL

HEAlTH PTSKS
Approach to Environmental Health Concerns of Individuals

Occupational and environmental medicine is the medical specialty dedicated to iden-
tifying, evaluating, treating, and preventing occupational disorders and, by cx-

TABLE 4.6
POTENTIAL HEALTH INDICATORS FOR ENVIRONMENTAL ASSESSMENT
General Indicators Mortality Morbidity
Perceived health Life expectancy at birth Asthma
Body mass index All causes of death Chronic obstructive diseases
Healthy life expectancy (age and gender standardized) Lung cancer
Birth weight Premature death (0-64) leukemia
Cause-specific deaths Stomach cancer
Mesothelioma
Skin cancer
Allergies/hypersensitivity
Cardiovascular diseases
infectious diseases
Congenital abnormalities
Chronic liver diseases
Occupational diseases
Spontaneous abortions
Acute poisonings
Clean
technologies
Cleane
[PRESSURE Production Consumption Waste
produchon:
release
waste
Resource Pollution Pot10

STATE Natural
hazards availability levels monitoring
and control
[-
EXPOSURE External Absorbed Target Education:

exposure dose organ dose Awareness
raising
FEFFECT Well-being Morbidity Mortality Treatment

Rehabilitation
Figure 4.6 Framework for environmental health indicators. Modified from Corvalan and
with permission.
Kjellstrom, 1995,
RISK MANAGEMENT 165

tension, to the evaluation of disorders suspected of arising from environmental
factors. Thus persons who believe they have developed a health prcblem caused
by the environment should consult a specialist in occupational and environmental
medicine, if possible.
Although the general field of occupational and environmental medicine has
a history that goes back to the writings of ancient times, the specialty started in
1700, when an Italian physician named Bernardino Ramazzini wrote the first
comprehensive treatise on the subject. In recent years the scope of occupational
medicine practice has expanded to include environmentally related disease as
well as disorders that are clearly work related. Except where the provision of spe-
cialized medical services is required by law, as in France, occupational medicine
is a small specialty worldwide and its practitioners tend to work for governments,
universities, or large companies. However, any physician can apply the essential
principles of occupational and environmental medicine. It is also possible for
physicians and other health professionals outside the specialty to play an im-
portant role in managing risk.
The first step in addressing a potential environmental health concern in an
individual is to identify whether one truly exists. The process here involves (1)
diagnosing the disease, which, in turn is based on symptom history and pattern,
physical examination, and laboratory investigations; (2) evaluating exposures;
and (3) determining, usually through literature review, whether the exposure
could have caused the diseases in question. Recognition of occupational injuries
is usually obvious. Recognition of occupational and environmental diseases, how -
ever, can be very difficult. Many occupational and environmental diseases look
like diseases from other causes and can be identified only by taking a careful oc-
cupational and environmental history. This is part of the physician's interview
when he or she asks patients what they have done for a living and to what they
have been exposed in their work and community. The occupational history gives
many clues that the physician can follow in determining whether a patient's
problem is work related.
Environmental diseases are often more subtle, but many cases do arise from
specific events, such as a pesticide spraying incident or an industrial accident in
the community. In environmental medicine, it is often difficult to know whether
an illness actually exists; patients are often referred for evaluation because their
physicians are not sure what the health effects of an exposure might be, and they
need reassurance of their diagnosis.
Diagnosis is usually less of a problem in occupational diseases than establish-
ing whether a condition is work related. For example, it may be difficult to prove
that a cancer was associated with exposure to asbestos 20 years before. Carpal tun-
nel syndrome, which is a painful neurological disorder caused by compression of
a nerve in the wrist, can be caused by many factors unrelated to work, such as
pregnancy and some diseases, but it can also be work related in people whose work
involves repeated motion of the wrists. Environmental diseases are often more dif-
ficult to pin down with certainty. Some conditions, such as cancer, and certain
types of lung disease may result from exposures that took place years before.
The second step in addressing an environmental health concern is usually
treatment. There is usually no special treatment for an occupational or environ-

mental disorder that is much different from the treatment of the same disorder
from any other cause. Removal from exposure is the most important aspect of
treatment.
The third step is rehabilitation, the process of overcoming and accommodat-
ing the results of the injury or illness. Usually, the healing process and therapy
will restore much of the function that has been lost temporarily after an injury,
but there may still he some permanent impairment. In occupational and envi-
ronmental disease, it is more common for the condition to present itself at a late
stage and for there to he limited potential for rehabilitation. As statistics over-
whelmingly illustrate, the longer the worker is away from wcrk following, for
example, a back injury, the less the chance of successful reintegration into the
workplace. Thus early intervention and early return to work using modified work
programs are essential. Similarly, the prognosis for recovery from a disease such
as occupational asthma is increased dramatically by early recognition and voca-
tional rehabilitation (i.e., removing the worker from exposure to an alternate
suitable job).
Impairment asses.cnient is the physician's measurement of the degree to which
the patient has lost function as a result of the disorder. For exaniple, reduced
strength or loss of motion resulting from an occupational injury can be mea-
sured, as can a patient's reduced capacity to breathe and perform physical activ-
ity because of lung disease. Unfortunately, pain cannot be measured objectively,
and this leads to many problems in impairment assessment. This assessment is
important in determining whether a worker can go back to work and the degree
of permanent disability that has resulted. Permanent disability is reflected in the
benefits given to a worker under workers' compensation and may figure into the
award given to a person who has sued in an environmental case.
In practice, there are almost always several members of the team tnvolved in
assessing and managing an environmental health problem, whether for a popu-
lation or for individuals. Box 4.6 gives an example of a multidisciplinary envi-
ronmental health team assessing and managing a common workplace health risk.
A-f aiza qing an E,im'iran,nenta/ i-lea/ti, Enicigency

A true environmental health emergency is best managed by a specialist with
training in toxicology, epidemiology, and public health. Such specialists are in
short supply, however, and may not be on the scene when an incident occurs.
Almost any health practitioner may he presented with a problem related to haz-
ardous exposures. En rural or remote areas, practitioners may have to serve, in
cooperation with public safety engineers and technicians, as consultants on en-
vironmental health hazards without preparation.
In discussing the role of the environmental health professional in managing
an environmental health emergency, we must consider four main areas: (I) what
the practitioner does in an emergency, (2) how the practitioner deals with cases
of suspected toxicity, (3) how the practitioner deals with the "worried well" who
fear toxicity but are probably affected, and (4) how the practitioner deals with
workers involved in clean-up operations. A careful methodological approach to
managing an emergency is )ust as important as having a detailed knowledge of
the hazards involved. Three commonsense steps are generally followed. The first
RISK MANAGEMENT 167

RflX 4
A Health Surveillance Program to Monitor the Risk

of Noise-Induced Hearing Loss
Noise control and hearing conservation provide an example of how occupational

health standards, periodic health surveillance, hazard control, personal protection,
occupational medicine, and company policies are interlinked to control an occupa-
tional health problem. Authors of the WHO Environmental Health Criteria on Noise
(WHO, 1980a) concluded that, although noise-induced hearing loss occurs at 75 dB,
many countries have adopted an occupational exposure level of 90 dB averaged
over an 8-hr working shift; it is considered too expensive to require reductions to
lower exposures. Factories and other workplaces that have noise levels approach-
ing 90 dB are required to carry out noise surveys; the noise is measured with sound
level meters and dosimeters (which average the noise over a work shift). If the noise
level averages 85 dB or more, the employer must put a hearing conservation pro-
gram into place, but as WHO investigators (I 980a) point out, it would be better to
establish such programs at 75 dB.
Hearing conservation measures include controlling sources of noise (through use
of acoustic tiles, soundproof containers, sound-absorbing niounts for vibrating equip-
ment, and whatever else is necessary), making available to workers an assortment
of personal hearing protection (ear plugs, ear muffs), and providing annual audio-
metric screening examinations. Using a device called an audiometer, a technician
tests the ability of workers to hear tones played at different frequencies; the loud-
ness required for the worker to first hear the tone is recorded as the threshold of
hearing. When workers lose hearing at a particular tone, it is called a permanent
threshold shift.
Noise-induced hearing loss starts with a specific loss at the frequency 4000 Hz
and gets worse thereafter. This is unfortunate, because this same frequency is the
mid-range of human speech, which means that workers who develop noise-induced
hearing loss find it difficult to understand speech and to follow a conversation. An
early sign of hearing loss is prolonged ringing in the worker's ears or a temporary
threshold shift in the ability to hear, which goes away after a few hours.
When these signs are present or a permanent threshold shift is first noticed, the
occupational physician must determine whether the cause is truly noise exposure,
whether the noise was associated with work (some workers listen to loud music,
have hobbies such as shooting guns, or have had their hearing impaired from gun-
fire in military service), and how great the impairment is. If a new case of noise-
induced hearing loss is identified, the system of protecting workers from hearing
loss has somehow failed and that part of the workplace where impairment occurs
requires attention to improve noise control.
All parts of this hearing conservation program must work together, including
the record-keeping, the prevention of noise-induced hearing loss, and identification
of new cases as early as possible while there is still time to prevent severe hearing
loss. This is also an example of how screening programs and other procedures ap-
plied to groups of workers end up benefiting individuals and identifying individual
needs.

step is to evaluate the problem; the second is to contain it; and the third and
main step in which the environmental health professional (or other practitioner)
is involved is management of the health effects (Guidotti, 1986).
Step 1: Evaluate The Problem The major role of the health practitioner at this
step is as an advisor and resource for technical information. To perform this role,
the health professional needs the most accurate possible information on the fol-
lowing:
What hazardous substances arc involved?

What are their toxic and safety hazards?
How many people have been exposed and how many may be exposed in the
near future?
Among these people, are there any who may be at exceptionally high risk?
This information may change constantly during a real episode. In a typical inci-
dent, there are innumerable false reports, doubts, and updates. The practitioner
involved must be prepared to be flexible.
Correct identification of the substances involved is essential. Labels on drums
may be misleading because drums are often recycled. Samples should he taken
by an environmental health specialist or industrial hygienist who wears suitable
personal protective equipment. Unless there is a compelling reason to act, such
as during a fire or a rapid leak, it is usually wise to let the material rest where
it is until the material is identified and suitable precautions can be taken. If an
emergency forces action before the material is identified, the only prudent move
is to assume the worst unless one has evidence that the material is not highly
toxic. Unidentified materials usually turn out to be fairly benign. Until they are
identified, however, they often cause great anxiety by requiring the use of full
protective gear by emergency response personnel. Once the identity of a mate-
rial is known, the hazard potential must be determined. There are a number of
sources of information on the toxicology and safety hazard of common indus-
trial and commercial chemicals.
Users of hazardous materials are required by law in many jurisdictions to keep
on file a Material Safety Data Sheet (MSDS) prepared by the manufacturer (sec
Chapter 3). The MSDSs usually give reasonable information on the safety haz-
ard of chemical formulations, but they are almost always incomplete in their de-
scriptions of the compound's toxic ellects and are usually weak or missing in-
formation on chronic effects. Many chemical formulations are proprietary
mixtures, thus their formulations are considered trade secrets and the MSDS may
not identify specific chemicals or their proportions. The MSDSs in the files of
many companies are also often incomplete, and not all pertinent MSDSs may be
available on short notice.
Other sources of information, such as medical libraries, are familiar to physi-
cians for clinical information. Law libraries also often have information On tox-
icology. Both usually carry the standard reference works in toxicology and can
order computerized literature searches for users. Many familiar medical texts have
RISK MANAGEMENT 169

BOX 4.7
Resources from Agencies in the International Program on
Chemical Safety
Material published by the WHO:
• Environmental Health Criteria (EHC( Series issued by the WHO/ILO/UNEP In-

ternational Program on Chemical Safety (IPCS) (--90 tit1es
• Health and Safety Guides (HSG) (90 titles)
• International Chemical Safety, Cards (JCSC) (-400 titles)
• Poison Information Monographs
• Concise International Chemical Assessment Documents
• Technical Report Series (TRS) covering environmental health or occupational
health issues
• IARC (International Agency for Research on Cancer) Monographs
• Special monographs on environmental and occupational health
• Guidelines for Drinking-Water Quality (3 volumes)
• Air Quality Guidelines for Europe
Materials published by the ILO:
• Encyclopedia of Occupational Health and Safety

• CIS (International Occupational Safety and Health Information Center) database
Materials published by the UNEP:
• International Registry for Potentially Toxic Chemicals (TRPTC) toxicity profiles and
legal titles
The IPCS is a joint program of the World Health Organization. the International Labor
Organization (1LO), and the United Nations Enviromnent Program (UNEP).
pertinent inforntation on toxic exposures. Poison Control Centers can be excel-

lent sources of information and advice. Box 4.7 lists reference materials available
from agencies in the International Program on Chemical Safety (1PCS) that pro-
vide information on specific environmental hazards.
The next part of the evaluation of a hazard presented by an incident is to find
out what is happening to the toxic material at the site. Once spilled, the waste
seeps into the ground, through the soil, and often into groundwater. The possi-
ble migration of the waste materials is an important issue to address in the ini-
tial assessment. A clear idea of how the chemical will spread is very important
in determining who is likely to become exposed to. For example:
If the incident is a gas leak, how many homes are downwind?

If the incident involves a liquid waste seeping into the ground, how many fam-
ilies draw their water from local wells?

If the liquid waste is flowing downhill as surface runoff, perhaps into a storm
drain or stream, where does the water go?
How many children in the area might play in or explore the site?
Will the prevailing winds carry a plume away from or toward residents?
If groundwater is contaminated, is drinking water or irrigation water likely to be
fouled?
If it rains or if SflOW melts, will surface run carry the waste off-site?
If drinking-water supplies are contaminated, must water he supplied to residents?
Not everyone in the community will actually be exposed, of course, and for pur-
poses of planning a medical response, it is important to consider the character-
istics of the persons who may actually come into contact with the material. Chil-
dren may develop skin rashes from direct contact: fumes may he merely annoying
to the young and healthy, but could be troublesome or life threatening to the
elderly, those who have cardiovascular or pulmonary diseases, to infants, or to
asthmatics. Pregnant women require special attention to protect mother and foe-
tus. Knowledge of the community at risk allows health authorities to warn sus-
ceptible individuals to take protective measures or to leave the area.
Step 2: Contain the Problem The next step in managing an environmental health
emergency is to establish control over the situation to minimize the potential of
exposure. This requires teamwork among police, fire, and public health author-
ities and obviously varies with the nature of the incident. The physician still serves
as an advisor in this step. In more complex situations, coordination among and
with local authorities is essential. Fire departments are usually best equipped to
handle safety hazards but often need advice and assistance in dealing with toxic
materials. The most difficult situations, such as fires involving multiple toxic sub-
stances, known and unknown, pose serious threats to public safety personnel
and may require on-site medical presence.
In extreme situations, evacuation may be unavoidable. The mental health
consequences of evacuation arc great and this extreme step should ncver be taken
without good reason. Large-scale population evacuations carry a high cost in
stress and safety, as well as the potential for violence.
An important aspect of containing the problem is to prevent public overre-
action. An incident like this provokes rumors and misinformation that must be
set straight to avoid panic or misguided interference in public safety measures.
Early establishment of a rumor control committee, a hotline, and good working
relations with the media can be very valuable. It is particularly important to fun-
nel all public information, whenever pcssiblc, through a single spokesperson.
Otherwise, slight differences of opinion, interpretation, and understanding may
look like confusion, uncertainty, and rivalry among responsible authorities.
Step 3: Manage the Health Effects Most practitioners feel uncertain and over-
whelmed when called on to deal with complex toxic exposures. Although these
cases are admittedly complex, there are certain guidelines that can be folk wed.
There are two separate problems that the health practitioner faces: evaluation of
RISK MANAGEMENT 171

persons who probably were exposed and evaluation of the "worried well" who
are concerned about the possibility of exposure and need to be reassured. Medical
emergencies involving hazardous substances are less common than situations in
which people believe themselves to have been exposed to a toxic substance and
seek medical evaluation. When the substance is known, an appropriate medical
evaluation can be derived. When the substance is not known or involves a com-
plex mixture, the appropriate medical evaluation may be difficult to determine.
Many incidents involve multiple exposures or substances that have multiple
effects. It is good practice to provide a basic comprehensive evaluation in all cases.
When an individual presents with a specific clinical complaint, it is important not
to focus the evaluation too narrowly because important findings may be missed.
A basic battery of tests may be recommended, but information collected may not
always be useful and careful thought must be put to ease of interpretation be-
fore tests are ordered.
An important role for the environmental health practitioner is the protection
of workers engaged in cleanup and control activities at the site. The practitioner
should inquire about the availability of suitable protective gear, decontamination
procedures, and the presence of security and emergency services. One should
emphasize to the workers the importance of not smoking and eating on the site,
of checking oxygen levels before entering any confined space, using the buddy
system (always working with a companion with access to rescue equipment),
and leaving contaminated clothes at the site. It is important to stress that man-
aging an environmental emergency is a multidisciplinary activity that requires
clear lines of authority, excellent communication with decision makers and the
public, and a strong sense of well-coordinated teamwork.
COST-EFFECTIVENESS AND COST-BENEFIT

ArJATYcTc OF TNTFPVFNTION
The use of benefit-cost analysis (BCA) in managing environmental health risks has
expanded rapidly in recent years. Basically, in this analytical technique the
present value of benefits is compared with the present value of the costs to de-
termine the net present value of the management option under review. Cost-
effectiveness analysis (CEA) is similar to BCA in its treatment of costs, however, the
consequences of interventions (i.e., results, impacts, effects, outcomes) are not
valued. Instead, the PUoSC of this analysis is merely to determine the costs in
relation to the benefit achieved, measured in terms of natural units, e.g., addi-
tional years of life, case of disease incidence, etc.
BCA 6- CEA provide practical techniques for determining whether resources
are being allocated efficiently in achieving objectives. In this regard they provide
powerful tools for planning 6- evaluating alternative programs related to envi-
roninental health risks.
In BCA the value of the benefits is compared with the value of the costs, with
each of these measurements entailing three steps: (I) identification of the type of
elfects, (2) quantification in concrete terms, and (3) valuation. First, all items of
cost must be identified, uninhibited by potential measurement difficulties. The
costs to be considered include the initial design and implementation of the pro-

gram, as well as the annual cost of enforcing and maintaining it. Producer costs
must be also identified, including, for example, the private sector's real resource
costs of complying with the regulations and the extent to which this will likely
be passed on to the consumer.
The second step is to determine how much each item will cost, and in which
year. It is important to include the degree of uncertainty associated with crude
measurements of cost estimates, which is best conducted in a sensitivity analysis.
In the third part of the BCA, valuation, these costs over time must be con-
verted into common values. Similarly, benefits as well as any potential ripple ef-
fects must he identified. Direct benefits may include lives saved on a statistical
basis, life-years gained, reduction in morbidity or mortality, and savings in the
cost of health care and social services because the population is healthier. Direct
economic benefits, such as increases in productive output, should also be in-
cluded, as well as the less direct health benefits, such as increased aesthetic value
of a cleaner environment, reduction in pain, fear, and anxiety, increased free-
dom from nuisance, and sense of fairness. The step of measuring these benefits
is considerably complex, as measurement of health effects associated with envi-
ronmental hazards is a subject of considerable uncertainty. Epidemiological stud-
ies are relatively insensitive in detecting small effects and there are discrepancies
between toxicological studies and human observations. The degree of uncertainty
must therefore also be taken into consideration in the overall analysis.
Finally, in order to be compared for policy purposes the value of health im-
provements converted into a common currency (such as U.S. dollars, yen, or
Deutsch marks in a particular year) or scale (such as lives or DALY5). The period
in which these improvements will occur is also specified (such as 5, tO, or 20
years). The steps involved in conducting BCA and CEA studies are summarized
in Table 4.7.
Many valuation methods are described in the environmental health litera-
ture. These include the cost-of-illness approach, which estimates direct and indi-
rect costs associated with the avoidance of disease damages together with costs
associated with any behaviors taken to avoid exposure to risk; and contingent val-
uation methods, which measure individuals' willingness-to-pay preferences in
monetary terms according to how they view changes in utility associated with
risk changes. This can be established by asking strategically designed questions
about how much individuals would he willing to pay for a certain reduction in
the risk of a certain health problem, or by comparing people's relative ranking
TABLE 4.7
SUMMARY OF STEPS INVOLVED IN CONDUCTING BENEFIT-COST AND
COST-EFFECTIVENESS ANALYSES
Define the study scope and objectives.
Define and measure the outcomes or effects of each option under analysis.
Identify, measure, and valtte all costs.
Identify, measure, and value all benefits.
Compare the costs with benefits, along with sensitivity tests of the magnitude of the costs and
benefits where uncertainty may exist regarding measures of outconhe or its value.
Define the implications of the results for presentation to decision makers.
RISK MANAGEMENT 173

BOX 4.8
Case Study—Pollution in Japan: Prevention Would Have
Been Better and Cheaper Than Cure
In the 1950s and 1960s Japan experienced a period of rapid industrialization and
economic growth, but little attention was paid to the environmental consequences.
The result was high levels of pollutants in the air, water, and soil in some areas and
several infamous outbreaks of diseases. Strong corrective action was taken in the
1970s and 1980s to redress the most severe problems. Three conclusions emerge
from the examples given below: allowing the release of toxic substances into the
environment can lead to serious health consequences and economic losses; pre-
venting the problem, as Japan is doing now, is less costly than cleaning it up; and
taking corrective action now is less costly than allowing problems to persist.
CASE 1: SULFUR DIOXIDE IN THE AIR
Between 1956 and 1973 one of Japan's largest petrochemical complexes was con-
structed at Yokkaichi City. By 1960 air pollution was causing local concern, and by
1963 1-hr average sulfur dioxide levels exceeded 2800 rg/m 3 , far above the WHO's
suggested maximum of 350 rg/m. In 1967 local residents successfully sued six com-
panies, claiming medical costs and compensation for lost income. Seven percent of
the total population of the district was certified to have been medically affected by
ambient air pollution. Increasingly stringent pollution measures were introduced in
1970, and by 1976 sulfur dioxide levels were in compliance with local standards.
Air pollution control costs since 1971, including technical installations and their
operauon, monitoring, and creation of environmental buffer zones, have been $114
million a year. Without this investment, however, medical expenses and compen-
sation would have been more than $160 million a year.
CASE 2: MERCURY IN THE WATER
At the turn of the century, Minamata was a scenic coastal town of 12,000 people
who made their living from wood products, oranges, and fish. In 1908 a fertilizer
plant was established that eventually became the Chisso Corporation, one of Japan's
largest manufacturers of chemicals. By the 1920s compensation for damage to fish-
eries had already become an issue, and in 1956 patients with a severe neurological
affliction, later to be called Minarnata disease, were observed.
In 1968, following extensive research, the disease was linked to the ingestion of
seafood containing high concentrations of methylmercury, a compound discharged
into Minamata Bay by the Chisso Corporation as a by-product of the manufacture
of acetaldehyde. The discharge of methylmercury peaked in 1959; it ended in 1968
when the company ceased production of acetaldehyde, but by then the floor of the
bay and its aquatic life had become heavily contaminated. Starting in 1974, 1.5 mil-
lion cubic meters of polluted sediment were dredged and removed.
By 1991, 2248 people (1004 of whom had died) had been certified as suffering
from Minamata disease and were eligible for compensation. An additional 2000 peo-
ple were pursuing claims for compensation. Had the discharge of mercury contin-
ued, the estimated annual costs of the damage, including paneni treatment and com-
pensation, sediment dredging, and losses to fisheries, would have been $97 million
a year. If acetaldehyde production had continued, pollution abatement through in-
plant waste recycling would have cost only $1 million a year.
Oflhj1ii, 1)
(continued)
CASE 3: CADMIUM IN THE SOIL
In the late 1940s a disease characterized by extreme generalized pain, kidney dam-
age, and loss of bone strength appeared in the Jinzu River Basin. The disease, which
primarily afflicted women, was called itai-itai ("It hurts, it hurts!") after the cries of
the sufferers. After two decades of research in 1968 the conclusion was drawn that
the cause was chronic cadmium poisoning, which was traced to the effluent from
the Mitsui Mining and Smelting Company located in the upper reaches of the basin.
The route for the cadmium poisoning was from river water to irrigation water to
129 people had been certified as itai-itai sufferers, and 116 of
soil to rice. By 1991,
them had died.
A major program of soil restoration was initiated in 1979. By 1992, 36 9% of the
contaminated area of 1500 hectares had been treated. Had the further release of
cadmium not been prevented, the annual costs from medical compensation, agri-
cultural losses, and soil restoration would have been $19 million a year. The costs
of prevention were $5 million a year.
Soutie: World Bank, 1993.
of different health stales where known probabilities can be used to assess the rel-
ative willingness to pay for improved health risks. (Details of these methodolo-
gies are beyond the scope of this basic text.) Similar techniques may he applied
to determine preferences among different health states SO that quality-adjusted
life-years can be used as a common denominator to compare the benefits of dif -
ferent risk reduction interventions.
The SCOC of the study is also important to define. Typically BCA studies are
microeconomic in focus and assume prices where quantities of other goods or
services remain unchanged as a consequence of the project or policy interven-
tion. Generally, for occupational health and safety interventions or relatively lo-
calized air or water pollution interventions, this assumption is reasonable. Flow-
ever, in the case of assessing the environmental health impacts of rapid population
growth, OZOflC depletion, and related global warming, the BCA framework may
be difficult to apply. Box 4.8 presents three cases in Japan that illustrate how
prevention would have been cheaper than the costs involved in treating and
compensating those affected by pcllution.
Increasing numbers of articles and textbooks are addressing BCA and CEA in
environmental health decision making. Principal issues in the use of economic
analyses in the environmental health field include the definition of options, the
perspective of the analysis, valuation, issues of benefit cost distribution, and the
scope of the study. Each of these will he addressed briefly below.
With respect to defining the options, it is generally accepted that a BCA or
CEA is not complete until an assessment is conducted for more than one op-
tion or alternative. In the environmental health area, this may entail alterna-
tive approaches, e.g., using alternative technology, regulation capacity, or in-
formation monitoring. The following example of residential radon exposures
illustrates how BCA can be applied by environmental health authorities to de-
termine the economic it1lplications of taking steps to reduce residential expo-
sure to radon gas.
RISK MANAGEMENT 175

Case Study: The Value of Reducing Residential Radon Exposure in Canada
When exposure to radon gas in homes was initially considered a potential envi-
ronmental health hazard in the 1970s, it was estimated that the Cost of reduc-
ing risks would he exorbitant. Subsequent examination has changed that view.
This case study provides a summary of how to assess the value of an environ-
mental health intervention. Discussed below are the points that should be un-
derstood to conduct such an assessment.
The Potential Health Risk In the case of radon, risk assessment evidence on the
health risks are well documented—by case studies, animal tests, and epidemio-
logical investigations. As early as 1556, excess deaths attributed to an unusual
and fatal chest disease were noted among Central European miners. Over the
years, as knowledge expanded, such disease became clearly linked to exposure
to radon and its radioactive decay products. Over 20 case–control studies of oc-
cupational cohorts have confirmed the association between exposure and lung
cancer. The International Agency for Research on Cancer (IARC) confirmed radon
as a lung carcinogen in 1988 (see Chapters 2 and 9 for discussion of radiation
and its health effects).
In 1988, a blue ribbon panel of experts organized by the (U.S.) National Re-
search Council's Committee on Biological Effects of Ionizing Radiation (BEIR-IV)
developed a consensus position on a dose–response model, with implications that
residential exposure could constitute a serious hazard. Epidemiological studies,
however, have not produced conclusive results. Nevertheless, while consensus
on this issue has not been reached, the suspicions about a connection between
radon and lung cancer have more evidence to back them up than other recog-
nized hazards have.
The Potential for Exposure Radon is a naturally occurring inert gas formed by
the radioactive decay of radium-226, which itself is a product of the decay of
uranium-238. It is present at varying levels of concentration in all rock, soil, and
water. While present in ambient air at low levcls, concentrations can he consid-
erably higher in closed structures (such as houses) if the gas is allowed to infil-
trate. Testing has confirmed that the distribution of radon in homes within a re-
gion tends to be log-normal (that is, most homes have low levels, whereas a small
number produce high readings). The levels observed, particularly at the higher
end, correspond to a range of exposures where a health effect would be expected,
especially considering the large numbers of people who arc potentially exposed.
The Cost of Prevention Although radon occurs naturally, the level to which hu-
mans is exposed is influenced by the technologies used in housing construction
and operation. Research has confirmed the effectiveness of various methods to
reduce exposure in new and existing homes—from better construction techniques
to active ventilation systems for blocking the entry of soil gas into a hime. The
costs, originally estimated from experimental work in the 1970s
at approximately
$7500 (Canadian) per home, have been revised downward substantially.

Evaluating Possible Interventions With information about the levels of radon ex-
posure and the costs of mitigating exposure, it is possible to carry out an eco-
nomic evaluation of various intervention options, following the steps identified
in Table 4.7. This analysis can provide decision makers with information about
the efficiency of alternate ways to use scarce resources. Preliminary analysis along
these lines has been carried out in Canada and the United States, as discussed
below. The following steps are widely accepted as a guide to conducting either
a BCA or CEA.
Step 1. Define the Study Scope and Objectives A Canadian study (Letourncau Ct
al. 1992), considered five different program options to reduce radon exposure
• change building codes

• test and mitigate (if needed) all existing homes
• test and mitigate (if needed) all existing homes and adopt building code change
• test and mitigate (if needed) at point of sale
• test and mitigate (if needed) at point of sale and change building codes.
Evaluation of these options provides a basis for
• estimating the relative benefits of different residential radon risk reduction op-
tions
• identifying the conditions (e.g., implications of acting at different exposure lev-
els that would result in the greatest benefit in relation to the costs.
Step 2. Select the Most Appropriate Outcome Measurement Because lung cancer
is the health outcome of concern, measures for determining cost-effectiveness
would include such things as cost per cancer case averted, cost per life saved,
and cost per additional life-year, or cost per radiation exposure reduction. These
measurements provide a way to summarize how much money would have to he
spent for each unit of benefit produced. This avoids ethical issues and other con-
troversies that must be encountered in estimating the value of each unit of ben-
efit (in other words, placing a dollar value on a life).
Step 3. Identify, Measure, and Value all Costs Costs were explicitly identified for
each program option under review, based on current practices and technologies
(notably at levels well below those that had been originally estimated from ex-
perimental remcdiation research). For example, the cost of a screening test was
set at $35, the cost of sub-slab depressurization for an existing home at $1 500,
etc. As costs in the options under review are incurred over a 10-year period,
these must be discounted (at a designated interest rate) to allow options to be
estimated at present values.
Step 4. Identify, Measure, and Value all Benefits Benefits were based on estimates
of the effectiveness of the mitigation in reducing exposure (measured in working
level months IWLMI of radiation exposure) and then estimating the health ben-
RISK MANAGEMENT 177

efit from the dose–response relationship produced by the BEIR-IV review (ap-
proximately 3.5 lung cancer cases per 10,000 WLMs of exposure). As this is the
sole measure of benefit, any questioning of the health effects of residential radon
exposure has tremendous implications for the economic analysis. Nevertheless,
the use of the BEIR-IV model (later confirmed by the BEIV-VI review [NRC,
1999]) is quite in keeping with the general protocol for considering risk man-
agement options. (Other health and economic benefits from reducing the level
of soil gas infiltration in a home [e.g., mildew, moulds] have not been included
in the analysis, but can be assumed to exist.)
Step 5. Compare Costs with Benefits (and Apply Sensitivity Tests) Results of the
Canadian study are provided in Table 4.8. At a national level (based on the results
of national testing conducted in 19 different cities to determine levels of exposure),
the greatest cost-effectiveness ($33,000 per WLM reduced) was determined to he
associated with the option of testing at point of sale and mitigating if concentra-
tions exceed the Canadian "action level" guideline of 800 Becquerels/m 3 .
Comparison of the right column with the left column shows that lowering
the action level (to 150 Bq/m 3 , which is in effect in the United States) for these
options nationally would make the cost-effectiveness more attractive—for ex-
ample, the cost-effectiveness ratio would be reduced to $15,000 per WLM re-
duction. (Sensitivity tests conducted to consider the implications of varying the
interest rate used to discount future costs indicated that the adoption of a 1 0%
discount rate would lower the cost-effectiveness ratio further—to $9000 per WLM
reduced.)
Comparison of estimates for a program to reduce radon risk in cities with high
and low mean levels of exposure showed that there can be dramatic differences
in the cost-effectiveness of preventing lung cancer cases. The two cities chosen
for comparison are a city with high exposure (Winnipeg) and one with lower
exposure (Vancouver). Analysis of BEIR-IV and others of the dose–response data
showed that for every exposure reduction of one WLM, four cancer cases could
he avoided. It would cost $8000 to avert one case of radon-induced lung cancer
in Winnipeg, but over $50,000,000 in Vancouver; Vancouver has high screen-
ing (testing) costs and very little mitigation, whereas in Winnipeg, a smaller city
with high exposures, there are much smaller screening costs and considerably
more mitigation.
T,BTE 4.8
COST-EFFECTIVENESS RATIOS FOR RADON MITIGATION OPTIONS IN CANADA
Cost-Effectiveness Ratio
($1 0001WLM Reduced)
National Application of Various Options @800 Bq/m 3 @150 Bq/m 3
Mitigate existing homes 54 25
Change building codes 75 -
Retrotit to changed building codes 74 64
Screen point of sale and mitigate 33 15
Screen point 01 sale and mitigate, and change building code 74 65
WLM, working level months, a unit ot radiation exposure

Step 6. Define Implications of Results for Decision Makers From the perspective
of cost-effectiveness alone, mitigation of residential radon exposure appears to
be an attractive option (as $8000 is not a high price to pay to avoid a case of
lung cancer). However, the implications of the options under review would en-
tail a large total expenditure of funds (another important policy consideration)
to achieve the benefit that could be realized. The total cost of the most attrac-
tive option nationally (point of sale testing and mitigation) would be $350 mil-
lion, based on the number of houses that would be tested. This would increase
to $1220 million if the action level of 150 Bq/m 3 were adopted, as more houses
vvould require mitigation.
The most practical implication of the analysis is that it would make the most
economic sense to target intervention (screening test and mitigation if necessary)
in areas of high-exposure risk, where the cost-effectiveness ratio of $8000 per
lung cancer case avoided would he of considerable interest, but $50 million may
be excessive. Thus, this CEA revealed that the screening/mitigation intervention
option is less cost-effective in areas of low radon concentrations, where the bulk
of total population exposure comes from homes with levels below the action
level, but is very cost-effective in smaller population groups where the exposures
are higher.
Stud9uestinnc
The construction of a depot for chemical waste is planned near a residen-
tial area. Several residents perceive this new situation as threatening to their
health and that of their families. Give examples of possible coping strategies that
can be characterized as emotion focused or problem focused.
Consider the advantages and disadvantages of a "best practical means" ap-
prcach as compared to an emission or effluent standard. Which best preserves
environmental quality in nonpolluted areas? Which best encourages the devel-
opment of new abatement technology? Which is most related to actual health
effects?
Think of an example of the use of immunization in an occupational health
context and consider the advantages and disadvantages of this practice. Should
this immunization be mandatory? Why or why not?
Consider whether you agree with the statement that personal protective
equipment should he a last resort. Why or why not? Under what circumstances?
Consider to what extent the control measures at the person, indicated for
the occupational environment, could also be effective to control for ambient
exposures. Indicate if you regard such control options desirable for the general
public.
RISK MANAGEMENT 179

S
AIR
LEARNING OBJECTIVES

• describe the importance of air quality as a determinant of health
• describe the nature and extent of air pollution—related diseases
• list the major sources of air pollution
• describe how air quality criteria are developed
• discuss the various approaches to prevention of air-related environmental
health problems
CHAPTER CONTENTS
Overview of Air Pollution Industrial Air Pollution
Aerosols Types of Industrial Air Pollutants
Gases Air Pollution from Industrial Acci-
Inhalation dents
Common Health Effects of Ambient Air Air Pollution in the Workplace
Pollution Air Pollution and the Community
Health Effects of Specific Air Pollutants Magnitude and Sources of Ambi-
Ozone ent Air Pollution
Sulfur Dioxide Ambient Air Quality Standards and
Oxides of Nitrogen Guidelines
Particles Control of Ambient Air Pollution
Carbon Monoxide Indoor Air Pollution
Volatile Organic Compounds
Trace Metals
OVERVIEW OF AIR POLLUTION

Air pollution is the result of emission into the air of hazardous substances at a
rate that exceeds the capacity of natural processes in the atmosphere (e.g., rain
and wind) to convert, deposit, or dilute thetri. Microbiological air pollution is
mainly a problem of indoor air and will he addressed in Chapter 8. Radioactive
compounds in air will be discussed in Chapter 9. Here we will focus on chemi-
cal pollutants in the air.
Air pollution is a problem of obvious importance in many places that affects
IVIII
human, plant, and animal health. For example, there is good evidence that the
health of about I billion urban dwellers is compromised daily because of high
levels of ambient air sulfur dioxide concentrations (see the section Control of
Ambient Air Pollution, below; WHO, 1997). Air pollution affects health most
clearly when compounds accumulate to relatively high concentrations, produc-
ing an adverse effect on the body, e.g., bronchoconstriction or other asthmatic
symptoms. Recent studies have shown that even low levels of exposure to fine
particles can produce illness and deaths in a community. Often, this effect is not
visible against the greater number of cases of illness or deaths caused by other
factors, such as hot weather. Air pollution can also affect the properties of ma-
terials (such as rubber), visibility, and the quality of life in general.
Although people have caused air pollution ever since they learned how to
use fire, anthropogenic air pollution has increased rapidly since industrialization
began. In addition to the common air pollutants, many volatile organic com-
pounds, inorganic compounds, and trace metals are emitted into the atmosphere
by human activities. Worldwide, almost 100 million tons of sulfur oxides (SO s ),
68 million tons of nitrogen oxides (NOr ), 57 million tons of suspended particu-

late matter (SPM), and 177 million tons of carbon monoxide (CO) were released
into the atmosphere in 1990 as a result of human activities. The Organization
for Economic Cooperation and Development (OECD) countries accounted for
about 40% of the SO S, 52% of the NO V, 71% of the CO. and 23% of the SPM,
as shown in Figure 5.1 (UNEP, 1992a). The reductions in some of the emissions
noted in the figure were likely due to regulation, education, changes in tech-
riology, and a rise in fuel prices in OECD countries.
The accumulation of chemically active compounds in the atmosphere is greatly
affected by land features and atmospheric movements. Valleys, nearby mountain
ranges, and the lack of open space (parks, forests, wilderness areas, bodies of wa-
ter) strongly increase the severity of air pollution in a locale. These features hold
the air mass like a container and prevent dilution and mixing. Stagnant air masses
IF7190
may receive emissions for days on end. When conditions are right, usually in the
1970
SOx 1980 OECD countries
1990
r —i rest of world
NO 1980
990
1 190
SPM
19701
Co 19801
____i1 990
0 20 40 60 80 100 120 140 160 180 200

Emissions (million tons / year)
Figure 5.1 Anthropogenic emissions of air pollutants. From UNEP, 1992a, with permis-
sion.
AIR 181
morning or when there is descent of air from higher altitudes, a special atmo-
spheric condition is created that is called an inversion. In an inversion, the tem-
perature rises with increasing altitude rather than falling, which is normally the
case. An inversion layer is a mass of air with an inverted temperature gradient
(warmer above, cooler below). The motion of air in an inversion layer is sup-
pressed and it limits the mixing and dilution of air pollution. Inversions are very
common, especially in valleys and coastlines. The worst episodes of air pollution
usually occur when inversions stay in place for days on end and the atmosphere
underneath receives air pollution day after day with no mixing or wind to di-
lute it.
Air pollution is a very complicated physical and chemical system. It can he
thought of as gases and particles that are dissolved or suspended in air respec-
tively. Many air pollutants interact with one another to produce their effects. The
severity of air pollution changes with the season, with daylight, with industrial
activity, with changes in traffic, with the prevailing winds, and with precipita-
tion (rain or snow), among many relevant factors. The composition of air pollu-
tion, theretore, is not constant from day to day or even week to week, but tends
to cycle. Average levels go up and down fairly consistently depending on the
time of year, but the actual levels are highly variable from one day to the next.
Aerosols
Small solid or liquid particles (line drcps or droplets) that are suspended in air
form a mixture called aerosols. Forming are complex systems in air pollution.
Aerosols often consist of a mixture of solid-phase particles, combined solid- and
liquid-phase particles, and sometimes liquid droplets suspended in air. Even
aerosols that are predominantly solid may contain absorbed water. On the coast,
some aerosols are formed by salt water droplets.
Dust consists of particles in the solid phase. The term is usually used for the
particles themselves or the accumulation of particles after they have settled or
have been deposited. When they arc up in the air, the particles are called sus-
pended particulate matter. This term is usually reserved for particles that are cre-
ated by dry pri cesses and are chemically and physically unchanged from the orig-
inal material except for their size. Smoke consists of particles in both the solid and
sometimes liquid phase and the associated gases that result from combustion.
Smoke is very complicated chemically and varies in composition depending on
what has been burned. Tobacco smoke and air pollution are both examples of
smoke and both undergo chemical transformations over time as they age. Ash is
the solid phase of smoke, particularly after it settles into a fine dust.
The most important characteristics of aerosols that determine their behavior
are size and composition. Size affects how the particle will travel in air and com-
position determines what will happen when it settles or lands on something. The
range in size of common particles associated with different constituents of air
pollution and occupational exposures is shown in Figure 5.2.
The individual particles in aerosols may he relatively uniform in size, or
monodispersed, or highly variable in size, or polydispersed. In nature, all aerosols
are polydispersed. Monodispersed aerosols are most commonly created for re-
search and for certain medications where it is important for the droplet or par-

Mtallurical dust and fufnes
.4
Sme!ter dust & fumes
4
Ammdnium chloride fUmes ¶oundry dust
4
-o Flour mill dust
a
cn
0 Sylfuric acid mist
0.
a 4
0 Ceflient dust
a 4
0 Pul'erizd coal
4
a Tobacco
a- Insecticide duts Plant spores
mosaic 4
0 virus
Bacteria
a
0
Pollens
4
Tobacco smoke
4 4-
Oil smokel Fly ash
I I I
0.0005 0.001 0.005 001 0.5 0.1 0.5 1 5 10 50 100 500 1000
Particle Size (tim)
Figure 5.2 Range of particle diameters from airborne dusts and fumes. Adapted from Levy
and Wegman, 1988, with permission.
tide to land at a certain place in the respiratory tract, as in asthma inhalers.

Aerosols in air pollution are all polydispersed. Fumes are polydispersed line
aerosols consisting of solid particles that often aggregate together, so that many
little particulates may form one big particle. Some gases, such as sulfate and ni-
trate, also may precipitate and then aggregate to form solid particles. Air pollu-
tion includes solid-phase particles and even droplets in a range of sizes, some of
which will behave one way while others behave differently. Larger particles are
kept up in the air by winds and local air movement and have a tendency to set-
tle out by the effect of gravity if the air is very quiet. The smaller particles are
kept up in the air by the movement of molecules in air (which is heat), a phe-
flOCflOfl called Brownian movement.
The size of particles in aerosol governs where the particles will tend to go in
the respiratory tract and that, in turn, determines some of the effects on the lung.
Size is also related to mass; the smaller the particle, the less the mass. In all poly-
dispersed aerosols, the greatest number of particles will be small but together
they will account for only a small fraction of the total mass; the larger particles
will be many fewer but will carry most of the mass. This is important because
some particles, such as those containing lead or mercury, will not necessarily
damage the lung but the mass of their toxic material may be absorbed and have
an effect elsewhere in the body.
Particles are generated with different size distribution depending on the
source. The composition of particles will depend on the local sources. Particles
from different sources may have different size distributions. Large particles are
most often the result of blowing dust or soot as the result of open combustion
and some are formed by aggregation of smaller particles. Large particles are mostly
solid but may contain adsorbed gases or he liquid on the surface. Smaller, and
AIR 183
especially fine particles are mostly caused by certain types of combustion, asso-
ciated with diesel exhausts, power plants, and other forms of rapid, hot com-
bustion. Small particles of around 10 ,im may also be formed by the aggregation
of fine particles, around 2.5 Am. Fine particles generally consist of a matrix of
carbonaceous compound, and dissolved or abscrbed or solid-phase sulfate, ni-
trate, and trace metals and some water. The effects of small particles on the body
are different from those produced by larger particles and are considered more
toxic. The composition of an aerosol determines the chemical reactivity of its par-
ticles and their density.
From the human health perspective, however, the most important aspect of
particle size relates to how a particle behaves in the respiratory tract. In discus-
sions of health a special measure of size, the aerodynamic diameter, is used, which
is different from the actual measurement of the particle and reflects the behav-
ior of a particle more accurately than a physical measurement would. The aero-
dynamic diameter of a particle is defined as the diameter of a sphere with a den-
sity of 1. This means that if the particle in question had the density of water they
would both settle at the same velocity. This measure allows one to compare par-
ticles that are different in shape, density, or mass. For example, a piece of fluff
(e.g., cotton) has a relatively large surface but a low density and will therefore
be easily suspended or carried away by the wind. Thus it has a small aerody-
namic diameter whereas its geometric diameter is relatively large. From this point
on in the text, the size of particles will be expressed in terms of the aerodynamic
diameter measured in micrometers. Larger particles have more mass and thus
more inertia; they are less likely to make it through the twists and turns of the
human respiratory tract.
The effect of particles on the body reflects the efficiency with which they pen-
etrate all the way to and within the lung and their chemical reactivity and tox-
icity once they arrive. Larger particles carry much more substance but are much
less likely to have an effect on the body because they do not penetrate into the
lower respiratory tract (belcw the first division of the windpipe, or trachea). The
largest particles, visible to the naked eye as specks of dust, are mostly filtered out
in the nose. Particles above 100 Am may be sources of irritation to the mucous
membranes of the eyes, nose, and throat but they do not get much further. Those
particles below this cutoff make up the inhalable fraction because they can be in-
haled into the respiratory tract. Particles larger than about 20 Am generally do
not enter the lower respiratory tract, below the throat (trachea). Those particles
below 20 im comprise the thoracic fraction because a high proportion can pene-
trate into the lungs. Particles below 10 Am enter the airways with greatest effi-
ciency and may be deposited in the alveoli, or airspaces, that are the deepest
structures of the lungs. Particles between 10 Am and 2.5 .tm are called coarse
particles. Particles below 2.5 lm are deposited in the alveoli with very high ef-
ficiency and are called "fine particles." Particles below 0.1 jm are called "ultra-
fine particles." Air pollution is predominantly in the coarse and fine range.
Notwithstanding the efficiency of penetration, ultrafine particles, smaller than
about 0.1 Am, tend to remain suspended in air and be breathed out again un-
less they carry an electrostatic charge. Thus, as a practical matter, the greatest
penetration and retention of particles is in the range 10.0 to 0.1 tm, which is

Approximate size (um) of deposited particles
100
20
Primary bronchi
10
ondary bronchi
Terminal
bronchioles
Figure 5.3 Deposition of dust Alveolar duct,

particles by size. From New- sac and alveoli
man, 1992, with permission.
called the respirable range. This is because particles in this range can be inhaled
all the way to the deepest structures of the lung. These patterns of deposition are
shown graphically in Figure 5.3.
Once in the lung, particles may have different effects, depending on their size.
Particles predominantly in the size range between 10 and 20 jim are more likely
to have effects on the airways. A large proportion of particles below 10 jim but
above 0.1 jim may be retained in the lungs. When they accumulate in large num-
bers and the lung responds to their presence, they may cause a type of disease
called pneumoconiosis; this is seen following high exposures, usually over several
years, in occupational settings. Pneumoconiosis is not a consequence of ambient
air pollution where the effects tend to be on airways rather than alveoli.
In air quality studies, the total aerosol suspended in air once was measured
as total suspended particles (TSP) or an optical measurement known as "British
Smoke." This measurement reflects the perception of smoke in the air and di-
minished visibility. These measurements are comparatively easy compared to
measurements of coarse and fine particles. PM 10 and PM2.5 have become the pre-
ferred measurements of particulate air pollutiin. Ultrafine particles are very dif-
ficult to measure.
Although disregarded for purposes of measuring the size of the particle, shape
is important in determining the effects of a particle. The human body handles
longer and thinner particics, called fibers, somewhat differently from particles that
are more rounded in shape because fibers are more difficult to remove from the
lungs by natural protective mechanisms. The very long and thin shape of fibres
of asbestos are particularly damaging to the lung and can cause lung cancer and
mesothelioma of the pleura. Fibers are described by the ratio of their length to
their width. A particle at least five times longer than it is wide is considered to
be a particle.
Liquid constituents of air pollution exist as aerosols, either as liquid-phase
particles, which are droplets, or in association with solid-phase particles. Liquids
that are constituents of air pollution are always aqueous, or water-based, because
AIR 185
droplets of more volatile organic compounds evaporate to the gaseous phase very
quickly. A cloud or dense collection of droplets is called a mist.
Small solid-phase particles also contain a small amount of absorbed water.
Both liquid- and gas-phase constituents of air pollution are often attracted to and
ride on the surface of solid particles; this is called adsorption (not to be confused
with absorption, in which the liquid or gas is actually taken into the particle).
The humidity in the atmosphere is an important determinate of the water
content of particles; the lower the humidity, the faster the water evaporates. A
particle may be reduced to a solid phase, which is called a droplet nuclei. Droplet
nuclei are small and easily inhaled and are particularly important in the spread
of some infectious diseases such as tuberculosis, when they come from an in-
fected person who coughs. Dry particles may also take on water when they are
released into a humid atmosphere. Small particles typically absorb large amounts
of water if it is available in the atmosphere; these are said to be hygroscopic.
Through this absorption mass is added to the particle and its capacity to carry
other dissolved constituents may be increased. Air pollution from the same types
of sources may therefore be different in humid climates and dry climates.
There are processes in the atmosphere through which liquid is converted to
gas and hack again or liquid is converted to solid. Volatile liquids may evaporate
to become gases. The evaporated compound in the gas phase is called a vapor and
behaves like a gas in air pollution. Droplets may also form from condensation of
vapor in a saturated atmosphere. Fog is a familiar example of an aerosol of liq-
uid water droplets that forms from condensation in an atmosphere saturated with
water vapor. Droplets may also form from ocean spray. Droplets often form by
condensation of liquid around a small solid particle. In coastal areas, the droplets
of seawater may evaporate to form solid-phase particulates that contain salt (this
is an important source of PM 10 near oceans).
Precipitation, in the form of rain and snow, reduces air pollution by dissolv -
ing soluble gases and by attracting and holding small airborne particles, bringing
theni down to the ground. The air may then be much cleaner, but the con-
stituents of air pollution in the rainwater or snow may present a serious prob-
1cm (acid rain; see Chapter 11, Acid Precipitation). Acid-forming compounds,
such as sulfates and oxides of nitrogen, reduce the pH in exposed lakes and soils
(surface water acidification), which if it exceeds the buffering capacity of the wa-
ter may lead to fish deaths and other ecological damage.
Gases
Air pollution can also consist of gaseous constituents, the iroperties of greatest
importance being solubilitv in water and chemical reactivity. At concentrations found
in air pollution, solubility is a major determining factor of the health effects of
gases. Relatively soluble constituents of air pollution include nitrogen oxides or
sulfur dioxide, which may be ionized in water and which in the atmosphere may
coalesce to form ultrafine particles and fine particles. In addition, a number of
gases occurring more commonly as occupational exposures are water-soluble, in-
cluding hydrochloric acid vapor and ammonia. Other gases, such as ozone, hy-
drogen sulfide, and organic compounds are less soluble.
Solubility for gases is much like size for particles; it is a characteristic that de-

termines the efficiency with which they penetrate deeply into the respiratory
tract. A gas that is soluble in water will be dissolved in the water coating the mu-
cous membrane of the lungs and upper respiratory tract and will he removed
from air passing more deeply. A gas that is insoluble in water will not be so re-
moved and will penetrate to the alveoli, the deepest structures of the lung, more
efficiently.
Gases that are reactive, such as ozone, tend to have their major effects on the
airways rather than the alveoli, even if they are relatively insoluble, except at
very high concentrations. They may irritate the walls of the airway and cause
bronchitis or induce asthmatic attacks, for example. Occupational exposures to
toxic gases or uncontrolled releases during an industrial emergency may expose
workers or local residents to much higher concentrations than they would ex-
perience in ambient air pollution. In such cases, the effects are correspondingly
severe and may result in serious toxic effects at the alveolar level, such as pul-
monary edema, a condition in which the damage to the lungs allows accumula-
tion of fluid in the lungs in a manner similar to drowning. In this situation, the
solubility of the gas is critically important as a determinant of toxicity.
As mentioned above, many gases, including ozone and sulfur dioxide, adsorb
onto the surface of particulates and penetrate deeply into the respiratory tract in
this way. When this happens, the effects may be different and greater than ex-
posure to either the particulate or the gas alone. The sclubility of a gas becomes
much less important as a determinant of its toxicity when it is adsorbed onto a
particle in the respirable range. Under these circumstances, it may penetrate much
more deeply than it would as a simple gas.
Inhalation
Inhalation of toxicants often constitutes the most rapid avenue of entry into the
body because of the intimate association of air passages in the lungs with the cir -
culatory system. On inhalation, soluble gases tend to dissolve into the water sur-
face of the pulmonary tract; insoluble gases generally penetrate to the alveolar
level. Because the alveoli bring the blood into very close and direct proximity to
air, gases may pass directly across the alveolar membrane and into the blood-
stream very efficiently. Particles, once deposited in the alveoli, may dissolve and
release their constituent compounds. The degree to which they enter the blood,
are circulated, and delivered to the body's tissues depends on the concentration
inhaled, duration of exposure, solubility in blood and tissue, reactivity of the
compound, and the respiratory rate. (The respiratory rate determines how much
air is breathed in and therefore the total amount taken into the body.) Unlike
many toxic substances that are ingested and therefore passed through the liver
and metabolized, inhaled compounds are not significantly metabolized prior to
circulation throughout the body. They may therefore have a direct and immedi-
ate effect, not unlike direct injection into the bloodstream. To understand the
health problems associated with airborne contaminants it is essential to have at
least a basic understanding of the structure and function of the respiratory tract.
Anything that decreases the partial pressure of oxygen in the alveoli reduces
the oxygen available for exchange and thus deprives the body of oxygen. At high
altitude, the partial atmospheric pressure is lower than at sea level and the cor-
AIR 187
responding pressure of oxygen in alveoli air also decreases, reducing the satura-
tion of blood with oxygen. When the oxygen in air is displaced by another gas,
so that there is not enough to support life, or when a person is prevented from
breathing, it is called asphyxiation. Substances that dilute or displace the oxygen
in air without any other effect are simple asphyxiants. Examples include carbon
dioxide, nitrous oxide, nitrogen, or hydrocarbons, such as natural gas. Com-
pounds that block the transfer of oxygen to the tissues or the utilization of oxy-
gen once it reaches the tissues are called chemical asphyxiants. The two most com-
mon examples of such inhibitors of oxygen uptake or utilization are carbon
monoxide (CO), which blocks the site on hemoglobin that binds and transports
oxygen, and hydrogen cyanide (HCN), which (in the form of cyanide) blocks the
pathway by which the tissues utilize oxygen. Carbon monoxide is particularly
common as a hazard resulting from incomplete combustion of fuels (such as in
automobile exhaust or open-flame heaters): It is especially dangerous because it
has no odor and thus gives no warning of exposure.
Chemical agents that irritate the lung may also impair oxygen uptake by other
means. Irritants may inflame the respiratory tract, causing bronchitis or provok-
ing an asthmatic attack or causing the lungs to be lilled with fluid (pulmonary
edema), a process much like drowning.
COMMON HEAlTH EFFECTS OF AMRTFNT AIR POT ITITTON
Respiratory symptoms are the most common adverse health effects from air pol-
lution (Table 51). Common symptoms include cough (which may produce spu-
tum), nose and throat irritation, and mild shortness of breath. These respiratory
symptoms are often associated with eye irritation and a sense of fatigue. Exac-
erbation of allergic symptoms is typical. Athletes often report that their perfor-
mance is off and that they become tired more rapidly when exercising dtiring
periods of high pollution levels. Asthmatics and patients with chronic obstruc-
tive pulmonary disease (COPD) often experience worsening of their symptoms
during air pollution episodes. Recent studies suggest a close association between
frequency and severity of asthma attacks and atmospheric oxidant and sulfate
levels. People with bronchitis may also experience more coughing due to in-
creased irritation of the bronchial mucosa. Acute upper and lower respiratory
tract infections also appear to occur more frequently in residents of areas with
higher pollution levels. Fever is not a feature of air pollution exposure alone and
suggests a possible infection.
Direct cardiovascular effects of air J)ollution are associated primarily with CO,
which is known to reduce oxygen delivery to the myocardium and suspected to
aggravate the process of atherosclerosis. These effects may occur in normal indi-
viduals who have no unusual susceptibility, but they are particularly severe
among people with existing heart disease.
Respiratory effects of air pollution, particularly in people who suffer from
chronic bronchitis, may place an additional strain on the heart as well. Air poi-
jurion is associated with increased risk of death from heart disease and lung dis-
ease, even at levels below those known to be acutely toxic to the lungs or heart.
It is thought that the compromise in lung function places an additional burden

TABLE 5.1
COMMON CONDITIONS TO WHICH AIR POLLUTION EXPOSURE
MAY CONTRIBUTE
How Air Pollution
Disease or Condition May Affect Condition Associated Factors/Comments
Acute bronchitis Direct irritative effects of SO 2 , Cigarette smoking may have a more
soot, and petrochemical than additive interaction
pollution
Acute respiratory Increased risk in young Poverty, malnutrition, exposure to
infections children inlectious agents
Asthma Aggravation from respiratory Usually preexisting respiratory allergy

irritation, possibly on or airway hyperactivity
reflex basis
Chronic bronchitis Aggravarion (increase in Cigarette smoking, occupation
Irequency or severity) of
cough or sputum associated
with any sort of pollution
Deaths Fine particulate increases Preexisting heart or lung disease
mortality in heart and lung
disease; mechanism is
unknown
Eye irritation Specilic effect of photochcmical Susceptibility diflers
oxidants, possibly aldehydes,
or peroxyacetvl nitrates;
particulate matter (fly ash)
acts as a lorcign body
Headache Carbon monoxide sufficient Smoking may also increase carboxy-
to lead to more than 10% hemoglobin, but not enough to
carboxyhemoglobin lead to headache
Lead toxicity Adds to body borden Close proximity to lead source;
exposure at home
on the heart, which cannot tolerate this. The stimulation of nerve rellcxes con-
necting the heart and the lung may cause additional problems in a diseased heart.
Mucosal irritation in the form of acute or chronic bronchitis, nasal tickle, or
conjunctivitis is characteristic of high levels of air pollution, although individu-
als vary considerably in their susceptibility to such effects. Eye irritation is par-
ticularly severe in the setting of high levels of particulates (which need to he in
the respirable range described and may be quite large soot particles) or of high
concentrations of pholochemical oxidants and especially aldehydes.
The link between cancer associated with the organic contents of air pollution
has always been a concern but an association has not been proven for ambient
urban air pollution, of the types described. There is little evidence to suggest that
community air pollution is a significant cause of cancer except in unusual and
extreme cases. Examples of cancer associated with community air pollution in-
clude point-source emissions from some poorly controlled smelters that release
arsenic, which can cause lung cancer. There are also important examples of in-
door air pollution in homes (radon) and workplaces (asbestos) that are linked to
AIR 189
lung cancer. Tobacco smoking is more carcinogenic than arsenic, radon, or as-
bestos in the air, multiplying the lung cancer risk from these toxins.
Central nervous system effects, and possibly learning disabilities in children,
may result from accumulated body burdens of lead. Air pollution contributes a
large fraction of exposure in many countries because of lead additives in gaso-
line. Even in countries where lead has been removed from gasoline the lead re-
mains in the environment as one source of exposure.
There are several documented occurences in which severe mortality from
many causes is associated with short-term exposure to fine particles. Air pollu-
tion has been associated in several severe episodes of high mortality, usually
among persons with pulmonary or cardiovascular disorders. Recent studies have
shown an association between particulates in urban air pollution and mortality
from a wide variety of causes, not just lung diseases. This finding was unexpected,
as the levels studied were much lower than those that had been previously linked
to increased mortality. The reason for the newer findings is probably that the
methods of statistically analyzing large populations are much better and the meth-
ods of measuring exposures, such as PM 25 , are much more refined than those
used earlier.
HEALTH EFFECTS OF SPECIFIC AIR POLLUTANTS

Some of the more common ambient air pollutants, their sources, and their health
effects are summarized in Table 5.2 and are described further below. It is im-
portant to understand that these pollutants are seasonal in their pattern. Both
ozone and sulfates, together with ultrafine particulates, lend to occur together
during the summer months in most developed areas. Ozone, oxides of nitrogen,
aldehydes, and CO tend to occur together in association with traffic, especially
in sunny regions. Some pollutants, such as radon, are only hazards indoors or in
a confined area, usually a workplace such as a mine. Others are present both in-
doors and outdoors, with varying relative concentrations.
Ozone
Ozone is a highly reactive compound that irritates airways in the lungs and in-
terferes with host defense mechanisms in the body. It also has an unusual effect
on breathing patterns as the result of changes in the reflex breathing mechanism.
In the lower atmosphere, oxygen, with light from the sun as a source of en-
ergy, reacts with nitrogen compounds and volatile hydrocarbons to create ozone.
This occurs especially in stagnant weather conditions and inversions under con-
ditions of sunshine, where there is ample time for the photochemical reactions
to take place. Ozone is chemically unstable and will react with a variety of sub-
stances. (The effects of ozone depletion in the upper atmosphere are discussed
in Chapter 11.) Ozone appears to trigger a reflex response in the lungs that al-
ters breathing patterns. People without asthma cannot inhale as deeply and will
have small changes in airflow.
Studies using pulmonary function testing have found that healthy persons
can experience adverse effects from ozone exposure. This is especially true when
they have an increased respiratory rate, for example when they are involved in

TABLE 5.2
SELECTED URBAN AIRBORNE POLLUTANTS, SOURCES, AND HEALTH EFFECTS
Pollutant Sourcea Health Effects

Acetic Acid Bioniass fuel combustion, Mucous membrane irrigation
construction materials
Aldehydes Biomass and fossil fuel Eye irritation, upper respiratory
combustion, cigarette tract irritation
smoke
Carbon tiionoxide Biomass and fossil fuel Headache, nausea, dtzztness,
combustion, cigarette breathlessness, fatigue, low birth
smoke, traffic weight, visual distttrhances, mental
confusion, angina, coma, death
Formaldehyde Biomass fuel combustion, Eye and resptratory tract irritation

construction and and allergies, possible cancers
frtrnishing materials,
cigarette smoke
Lead (and Leaded gasoline, smelting Neuropsychological effects, central
other heavy nervous system damage, learning
metals) disabilities
Microorganisms Furnishings, humans, Infectious disease, allergies

animals
Nitrogen oxides Biomass and fossil fuel Eye irritation, respiratory tract
combustion, cigarette infection (childreti are especially
smoke, traffic vulnerable), exacerbation of
asthtiia, irritation of bronchi
Ozone Traffic, hydrocarbon release, Eye irritation, respiratory tract

fossil fuel combustion sending irritation, redttced exercise capacity,
pollutant) exacerbation of respiratory disease
Particulates Biomass and fossil fuel Eye irritation, respiratory tract

combustion, furrtishing infections, allergies, exacerbation
and construction materials, of respiratory and cardiovascular
cigarette smoke, industry, disease
traffic
Phenols Biomass fuel cottihustion, Mucous membrane irritation
household chemicals
Polycyclic aromatic Fossil fuel combustion, traffic, Includes carcinogens
hydrocarbons acute incineration
Radon Underlying rock and soil Carcinogen
Suhftir oxides Biontass and fossil fuel Respiratory tract irritation, impaired
combustion, indttstrial pulmonary function, exacerbation
emissions of cardiopultnonary diseases
Sulfuric acid (formed Biomass and fossil fttel Respiratory tract infection,
by sulfur oxides combustion, industrial bronchospasm
in air( emissions
Volatile organic Biomass and fossil fuel Headache, dizziness, upper
hydrocarbons combustion in traffic, respiratory tract irritation, nausea,
furnishing and construction inclttdes carcinogetts
materials, hottsehold chemicals
f1ay he a soorce of emissions (most, source of release (e.g., raton or source of emissloos that give rise to
secon cfd ry pollutants I e.g., oz ne, aldehydes
AIR 191
a 100
C
o Upper respiratory symptoms
0 90 • Non respiratory symptoms
A Lower respiratory symptoms
E 80
0
0
E>. 70
60
Cs
5)
E 50
0.
:3
0
40
C)
5) 30
Cs
C) 20
a
C)
C) 10 __o-- Figure 5.4 Effect of ozone on
0 respiratory symptoms. From
0 1000 2000 3000 4000 5000 Kleinman ci al., 1989, with
Effective Ozone Dose (micrograms detvered in 2 hr) permission.
outdoor physically strenuous activities. A dose—response curve for the symptoms

associated with ozone is presented in Figure 5.4. Symptoms include upper res-
piratory symptoms (nasal discharge, throat irritation), lower respiratory symp-
toms (cough, wheeze, chest pain), and nonrespiratory symptoms (headache, fa-
tigue).
Kleinman et al. (1989) produced a dose—effect curve indicating how pul-
monary function tests vary with dose of 0 3 (see Fig. 5.5). Over a short period
the effects of ozone are cumulative. After several days, however, people become
stquaresfit 0
tolerant to ozone and have fewer symptoms. Their breathing becomes more nor-
mal, but persons with asthma may still develop airflow obstruction. Within a
brief period, the inflammation produced by the irritant effect of ozone results in
a reduction of airflow and a worsening of asthma. Ozone also appears to make
persons whose asthma is triggered by allergies more susceptible to the allergen.
Ozone may provoke asthmatic attacks in people who already have asthma, al-
though ozone does not appear to cause the disease in the first place. The attacks
tend to occur 1 or 2 days after the ozone concentration is at its highest, not dur-
>
ing the peak.
20
A 0.1 ppm
• 0.2 ppm
• 0.3 ppm
o 0.4 ppm
15
0
>
Ui
U-
. 10
a
C)
0
Cs
.0
0
5
0
• Figure 5.5 Effect of ozone on

0 I I pulmonary function. From
0 1000 2000 3000 4000 5000
Kleinrnan ci al., 1989), with
Effective Ozone Dose (micrograms) permission.

BOX 5.1
London Fog
On December 5, 1952, a phenomenon known as a temperature inversion occurred

in the atmosphere in London, England. This resulted in a dense fog forming in the
center of the city. (During a temperature inversion very little air movement occurs,
and air, including the particulate matter and other pollutants it contains, gets trapped
in a given location. Suspended matter in the air can provide nuclei on which par-
ticles of moisture and other pollutants, such as acids, are deposited.)
During this time, the temperature hovered around 0°C. The burning of fossil fu-
els (coal) in open hearth fires in homes, in the industrial generaticn of electricity,
and the emissions from transportation vehicles contributed to the atmospheric pol-
lution. Measurements for total suspended particulate matter (TSPM) and sulfur diox-
ide were routinely made in both central and peripheral London during this time.
During December 6-8, 1952, daily averages from all monitoring points increased
about fivefold to 1.6 mg/rn 3 . Peak values were 3 to 10 times the normal values, and
were highest in central London. In comparison, the mean December 1957 concen-
tration for TSPM was in the range of 0.12 to 0.44 mg/m 3 .
The demand for hospital beds increased on December 8, and the central Lon-
don hospitals issued an Emergency Bed Warning that they had sufficient beds for
fewer than 850/ of applicants. The mortality rate in certain parts of London in-
creased dramatically during this time (see Fig. 5.6). The mayor causes of death were
a variety of respiratory-related illnesses, cardiac illness, and ill-defined illnesses. At
least a few deaths were caused by injuries and a few people drowned when they
could not see and fell into the Thames River. In addition, many animals )e.g., cat-
tle) had to he slaughtered because of illness during this time, likely because of the
fog.
Based on the epidemiological data collected during the London smog episodes,
it was felt at the time that the increased number of deaths in London during the
fog was more closely related to the particulate matter in the air, rather than the
SO 2 . A reanalysis later, though, suggested that the acid aerosols (e.g., sulfur diox-
ide) were the major factor in causing the increased mortality.
Adapted by A. Marliarn; from Kjcllstrd;n and Kicks, 1991.
Sulfur Dioxide
Sulfur dioxide (SO 2 ) has been a serious problem in air pollution since the earli-
est days of industrialization. II has been the major problem in reducing (see sec-
tion Industrial Air Pollution, below) or acidifying air pollution during the period
of rapid economic growth in many countries. It was one of the major cornpo-
nents of the so-called London Fog, which had serious direct health effects, as il-
lustrated in Box 5.1 and Figure 5.6.
Soon after the London Fog incident experimental studies of the effects of sul-
fur dioxide on humans showed that, at least in acute exposures, concentrations
of up to 8 ppm caused respiratory changes that were dose dependent. Later stud-
ies revealed that the main effect of sulfur dioxide is bronchoconstniction (closing
AIR 193
90
80 /
/ \\LAC
70
0
/
o 60 /
0
0
o 50 /
40
30 I/OR
0
—————
20
10
0
8 15 22 29 6 13 20 27 3 10
Nov Nov Nov Nov Dec Dec Dec Dec Jan Jan
Date
Figure 5.6 Weekly death rates in London Administration County (LAC) and the outer
ring (OR) 1 November 1952-10 January 1953. From WHO, 1998b, with permission.
of the airways causing increased resistance to breathing), which is dose depen-

dent, rapid, and tends to peak at 10 mm (Folinsbee, 1992). Persons with asthma
are particularly susceptible and in fact asthmatics suffer more from the effects of
sulfur dioxide than does the general public. Persons with asthma who exercise
will typically experience symptoms at 0.5 ppm (1.4 mg/m 3 ), depending on the
individual.
Sulfate, a major sulfur-containing ion in water, is a major constituent of air
pollution capable of forming acid. Sulfate itsell appears to trigger bronchocon-
striction in persons with vulnerable airways and it is a major constituent of ul-
trafine particulates. There are other acid ingredients in air pollution, such as ni-
tric acid, but less is know about them. Through their emission into the air by
industry and motor vehicles, these acids cause a phenomenon known as acid rain.
This is discussed further in Chapter 11.
Because of the small size of acid-forming aerosols such as sulfur dioxide, sul-
fates, and nitrogen dioxide and their tendency to ride along on particles, these
aerosols can deposit deeply in the distal lung and air space. Combined with ozone
they appear to provoke airways responses in an additive or synergistic manner.
They have also been implicated in causing mortality in association with ultrafine
particulates.
Oxides of Nitrogen
As mentioned above, nitrogen compounds, especially nitrogen dioxide, are in-
volved in the formation of ozone at ground level. The oxides of nitrogen also
produce adverse health effects and are important air pollutants in their own right.
Nitric oxide (NO) is produced by combustion. Nitrogen dioxide (NO 2 ), which
has greater health effects, is a secondary pollutant created by the oxidation of
NO under conditions of sunlight, or it may be formed directly by higher-
temperature combustion in power plants or indoors from gas stoves. The direct

TABLE 5.3
POTENTIAL HUMAN EFFECTS OF NITROGEN DIOXIDE
Health Effect Mechanism
Increased incidence of respiratory infections Reduced effectiveness of lung defenses
Increased severity of respiratory infections Reduced effectiveness of lung defenses
Respiratory svniptoms Airways injury and bronchospasm
Reduced lung function Airways and possibly alveolar injury
Worsening of the clinical status of persons with Airways injury and reduced cilectiveness
asthma, chronic obstructive pulmonary diseases of host defences
or other chronic respiratory conditions
Source: Samet and IjIell, 1990.
effects of NO include increased incidence of infectious lower respiratory disease

in children (including long-term exposure as in houses with gas stoves) and in-
creased asthmatic problems. Extensive studies of the oxides of nitrogen have
shown that they impair host defenses in the respiratory tract, increasing the in-
cidence and severity of bacterial infections after exposure. They have a marked
effect in reducing the capacity of the lung to clear particles and bacteria. Nitric
dioxide provokes bronchocoristriction and asthma in much the same way as ozone
but it is less potent than ozone in causing asthmatic effects.
Despite decades of research, the full effects of NO 2 are not known. Known
human health effects are summarized in Table 5.3. Other effects are known but
difficult to evaluate. For example, NO has a major effect on blood distribution in
the lungs. In animals, it has been shown that exposure to NO 2 makes cancerous
metastases from the lung much more likely to appear elsewhere in the body, al-
though NO 2 itself does not cause cancer. Nitric dioxide is also a significant con-
tributor to acid precipitation (see Chapter 11).
Particles
Particulate matter in the air (aerosols) is associated with an elevated risk of mor-
tality and morbidity (including cough and bronchitis), especially among popula-
tions such as asthmatics and the elderly. As indicated earlier, they arc released
from fireplaces, wood and coal stoves, tobacco smoke, diesel and automotive ex-
haust, and other sources of combustion.
In recent years we have learned a great deal about the health effects of par-
ticles. As noted above, fine particulates in urban air pollution, below 2.5 /.rrn in
diameter, differ in their chemical composition from larger particles. Larger par-
ticulates that are included in PM 10 (particulates 10 rm and smaller) consist mostly
of carbon-containing material and are produced from combustion; some fraction
of these is produced by wind blowing soil into the air. These larger particulates
do not seem to have as much effect on human health as the smaller particulates.
Particulates in the fraction PM25 (2.5 rm and below) contain a proportionately
larger amount of water and acid-forming chemicals such as sulfate and nitrate,
as well as trace metals. These smaller particulates penetrate easily and completely
into buildings and are relatively evenly dispersed throughout urban regions where
they are produced. Unlike other air contaminants that vary in concentration from
place to place within an area, PM 25 tends to be rather uniformly distributed.
AIR 195
The health effects of PM25 CO. sulfate, and ozone cannot be easily separated
because they tend to occur togethcr in urban air pollution. Recent research
strongly suggests that at least PM2 , 5 and sulfate, and probably ozone as well, are
associated with an increase in deaths in affected cities. The higher the air pollu-
tion levels for these specific contaminants, the more excess deaths seem to oc-
cur on any given day, above the levels that would be expected for the weather
and the time of year. Likewise, depending on the time of the year and the
weather, there are more hospital admissions for various conditions when these
contaminants are high. Ozone in particular is linked with episodes of asthma,
but all three elements seem to be associated with higher rates of deaths from and
complaints about lung disease and heart disease. It is not yet known which is
the predominant factor in the cause of these health effects; some combination of
each may be responsible for some effects.
At the much higher concentrations of CO, sulfate, and ozone encountered in
many developing countries, the health effect is likely to be proportionately
greater. There are many factors that complicate such studies in developing coun-
tries. The very high rates of respiratory disease during the winter among even
nonsmokers in some northern Chinese cities, for example, have been attributed
to air pollution, and although this is likely to be true, cigarette smoking, indoor
air pollution from coal-fired stoves, crowded conditions, and the risk of viral in-
fections may also be important factors.
Carbon Monoxide
Carbon monoxide is produced primarily by the incomplete burning of fossil fu-
els—for example, by cars and other gasoline-powered engines and by charcoal
or oil heaters. As it is odorless, cokrless, and slightly heavier than air, it tends
to collect in confined spaces and affects people without warning. The written his-
tory of CO goes back centuries, as Roman records discuss deaths associated with
fires in enclosed spaces.
Basically, as CO concentrations go up, the oxygen-carrying capacity of the
blood goes down, because oxygen molecules are literally being replaced by CO
molecules and the ability of hemoglobin (carboxy-hemoglobin [COHb]) to bind
oxygen depends on 02 binding at neighboring sites. The CO molecule's bond to
hemoglobin is 200-300 times stronger than the hemoglobin-oxygen bond, so CO
TABLE 5.4
PREDICTED CARBOXYHEMOGLOBIN LEVELS FOR SUBJECTS ENGAGED IN
DIFFERENT TYPES OF WORK
Carbon Monoxide
Concentration Predicted COHb Level for those Engaged in
Exposure
(ppm) (mg1rn3 ) Time Sedentary Work Light Work Heavy Work
100 115 15 min 1.2 2.0 2.8
50 57 30 inin 1.1 1.9 2.6
25 29 1 hr 1.1 1.7 2.2
tO 11.5 8 In 1.5 1.7 1.7
Source: WHO, I 987a

TABLE 5.5
HUMAN HEALTH EFFECTS ASSOCIATED WITH LOW-LEVEL CARBON MONOXIDE
EXPOSURE: LOWEST OBSERVED ADVERSE EFFECT LEVELS
Carboxyhemoglobin
Concentration (%) Effects
2.3-4.3 Statistically significant decrease (3%-7%( in the relation between work
time and exhaustion in exercising young, healthy men
2.9-4.5 Statistically significant decrease in exercise capacity (i.e., shortened dura-
tion of exercise before Onset of pam) in patients with angina and in-
crease in duration of angina attacks
5-5.5 Statistically significant decrease in maximal oxygen consumption and
exercise time in young, healthy men during strenuous exercise
<5 No statistically significant vigilance decrements after exposure to carbon
monoxide
5-7.6 Statistically significant impairment of vigilance tasks in healthy experi-
mental subjects
5-17 Statistically significant diminution of visual perception, manual dexterity,
ability to learn, or performance in complex sensorimotor tasks (e.g.,
driving(
7-20 Statistically significant decrease in maximal oxygen consumption durmg
strentious exercise in young, healthy men
Snorer: WHO, 1987a
is not cleared easily from the circulatory system. Exposure to short periods of
high-concentration CO is just as bad as long periods of low concentrations. Car-
bon monoxide is also a messenger molecule in the human nervous system and
some of its effects may be direct
Normal amounts of CO in the blood are in the range of 1%. Smokers can have
higher concentrations, around 3%-5%, and if one were to exercise at rush hour
in heavy traffic (at 10-15 ppm), levels of 3%_4% could be expected. Different pre-
dicted COHb levels for subjects engaged in different types of work are shown in
Table 5.4. Different lowest observed adverse effect levels (LOAELs) are shown in
Table 5.5. Exercise tolerance does not seem to be decreased until after a level of
about 5% is reached in healthy subjects. People at increased risk include thcse with
heart and lung problems. Follinsbee (1992) found that "for every 1% increase in
COHh there was a 4 0% decrease in time to ischaernic changes." At low levels of CO
exposure, symptoms include fatigue, headaches, and dizziness, but higher concen-
trations of around 3%-5% can lead to impaired vision, disturbed coordination, nau-
sea, and eventually death. To prevent COHb levels from exceeding a 2.5% to 3%
level in the nonsmoker, the following guidelines have been proposed: a maximum
permitted exposure of 100 mg/rn 3 for <15 mm; 60 mg/rn 3 (50 ppm) for <30 mm;
30 mg/m 3 (25 ppm) for <60 mm, and 10 mg/rn 3 (9 ppm) for 8 hr (WHO, 1987a).
Volatile Organic Compounds

Volatile organic compounds (VOC) include bcnzcne, chloroform, methanol, car-
bon tctrachloride, and formaldehyde, among hundreds of other compounds.
Gasoline is a mixture of many such compounds. In the past two decades some
261 VOCs have been detected in ambient air. While most of these chemicals oc-
AIR 197
cur in the environment at very low levels, some are highly reactive. Like nitro-
gen compounds, they cause indirect effects (such as helping to create ozone) as
well as having direct human physiological effects. They may originate from house-
hold products such as painting supplies, dry cleaning establishments, refineries,
gasoline stations, and many other sources. They can cause irritation to the res-
piratory tract (from increased rhinitis, or runny nose, to asthma) as well as
headaches and other nonspecific complaints. At high concentrations, VOCs have
markedly toxic effects, some of which vary by compound, but which include
neurological effects in all cases. Direct toxicity from VOCs is primarily an indoor
air pollution problem and an occupational hazard, as levels indoors and in the
workplace can reach many times that of outdoor levels.
Trace Metals
The trace metals include cadmium, mercury, zinc, copper, lead, and a dozen oth-
ers. These are called trace elements because they are present in the environment
or body only in small amounts. Human activity has led to the increase in release
of these elements into the environment. Trace metals may have direct health ef-
fects on the nervous and respiratory systems, such as liver and skin.
Lead is the best studied of these trace metals. It is known to be a highly toxic
substance that particularly causes nerve damage. In children, this can result in
learning disabilities and neurobehavioral problems. An estimated 80%_901% of lead
in ambient air is thought to be derived from the combustion of leaded petrol. Be-
cause of its effects on the behavior and learning abilities of children even at low
levels of exposure, efforts throughout the world are being directed at removing
lead from gasoline and consumer products such as house paint. The WHO guide-
lines value for long-term exposure to lead in the air is 0.5-1.0 tg/m 3 /year (WHO,
1987a). Lead is discussed further in Chapter 10 as an occupational hazard.
Other trace metals that occur in air pollution include mercury, vanadium, and
iron; all at very low concentrations.
INDUSTRIAL ATR POLLUTT()N
Types of Industrial Air Pollutants

Industrial air pollution occurs as the result of the release of pollutants (called
emissions) into the atmosphere. The pollutants mix in air and are diluted but may
travel long distances on slow, steady winds if an industrial chimney is tall enough
to propel them high into the atmosphere. A fundamental problem of air pollu-
tion science is the difficulty of measuring pollutant concentrations accurately.
There are three general types of industrial air pollution as defined by their
different chemical characteristics, distribution, and sources (outlined in Table 5.6).
Reducing air pollution is caused by the emission of SO 2 and particulates, substances
that are chemical reducing agents in the atmosphere. Emissions of SO 2 are caused
by burning fossil fuels containing sulfur; emissions of particulates occur most
heavily when combustion is inefficient. Reducing air pollution is produced pri-
marily by fossil fuel power plants, industrial furnaces, steel mills, and large dicsel-
powered vehicles.

TA8IF 5.6
TYPES OF AIR POLLUTION BY CHEMICAL CHARACTERISTICS AND SOURCE
Type Composition Source
Reducing Sulfur dioxide, partictilates Stationary combustion sources,
suh as fossil fuel power plants,
industrial furnaces, home heating
units
Photochemical Hydrocarbons and nitric oxide Mobile emissions sources such as

emitted by the internal combustion cars, fossil fuel powerplants,
engine undergo complex photochemical petrochemical plants, and oil
reactions in the presence of sunlight, refineries
resulting in an atmosphere with
significant concentrations of
ozone, nitrogen dioxide, aldehydes,
and organic uitratcs
Point source Specific to source of emission. e.g., Specific industries; industrial or
lead near asmelier transportation accidents -
Photocliemical air pollution, much newer in human history, results from com-
plicated chemical reactions in the atmosphere that are driven by the energy in
sunlight. In photochernical smog, emissions rich in oxides of nitrogen and hy -
drocarbons undergo reactions to produce ozone, specific compounds of nitrogen,
and aldehydes—all of which are highly reactive and chemically oxidizing. This
type of smog is caused primarily by automobile traffic, to which are added emis-
sions from stationary sources, such as hydrocarbons from gasoline and dry clean-
ing solvents and oxides of nitrogen from power plants. Many cities have been
able to bring reducing air pollution under control. However, as automotive traf-
fic has increased worldwide, photochemical smog became a problem. This type
of air pollution may occur in settings that do not have a concentration of in-
dustry, if there is enough motor vehicle traffic. It is most common, and usually
most severe, where the sunlight is strong and temperatures are warm because
these conditions favor the chemical reactions that are characteristic of this form
of air pollution. Because these characteristic chemical reactions takes time, pho-
tochemical air pollution is often worse downwind of the source and several hours
after peak emissions.
A third type of industrial air pollution is point-source emissions, which affects
the immediate vicinity of the plant but does not usually involve atmospheric re-
actions to any great extent. Examples include lead in the vicinity of a smelter,
hydrogen sulfide from a sour gas plant, pesticides from agricultural application,
and concentrated fumes from a spill or tank rupture. Such emissions arc fre-
quently the result of accidents, particularly those related to transporting haz-
ardous substances by truck or train.
Air Pollution from Industrial Accidents

Industrial activities or accidents may release a relatively large quantity of a spe-
cific type of air pollution that becomes a local problem. Severe episodes that have
been well-documented include one in Belgium in 1930 (Meuse Valley), one in
AIR 199
BOX .S.2
Bhopal: Case Study of an International Disaster
Arguably, the world's worst industrial cataclysm occurred on December 2, 1984 at

the Union Carbide Plant in Bhopal, India, where a release of a gas cloud of methyliso-
cyanate (MIC) killed over 3800 people. What was described in one report as a "nor-
mal accident" was apparently initiated by the introduction of water into the MIC
storage tank, resulting in an uncontrollable reaction, with liberation of heat and es-
cape of MIC and other decomposition products in the form of a gas. Safety systems
were either not functioning or were inadequate to deal with large volumes of the
escaping toxic chemicals. Among the more than 200,000 persons exposed to the
gas, the initial death toll within a week following the accident was over 2000. By
1990, the Directorate of Claims in Bhopal had prepared medical folders for 361,966
of the exposed persons. Of these, 173,382 had temporary injuries and 18,922 had
permanent injuries, with the recorded deaths totaling 3828.
One of the most important lessons of the Bhopal tragedy is how important it is
to prevent these incidents by taking action in advance. Environmental legislation,
preventive maintenance strategies, worker-training programs, environmental edu-
cation programs, research on intermediate products, development of systematic haz-
ard-evaluation models, emergency planning, and disaster preparedness are all ex-
amples of such activity.
Source: Dhara and Dhara. 1995.
the United States in 1948 (Donora, Pennsylvania), one in Mexico in 1950 (Poza
Rica), two in England in 1952 and 1962 (both in London; see Box 5.1), and one
in India in 1984 (Bhopal). The Bhopal incident is presented in Box 5.2.
Air Pollution in the Workplace

Airborne hazards are common problems in occupational health; these are dis-
cussed more fully in Chapter 10. Several diseases are known to he caused by in-
halation of substances found in particular occupations. For each category of dis-
ease noted previously in Common Health Effects of Ambient Air Pollution, there
are long lists of workplaces where such diseases have been documented to be
excessive because of inadequate air quality controls. The incidence and preva-
lence of these conditions have changed over time. For example, the fibrotic lung
diseases (pneumocomosis that causes scarring of the lungs), which used to be
quite prevalent, still occur in developing countries where exposure controls are
inadequate. This category of diseases includes silicosis, asbestosis, coal miners'
pneumoconiosis, and others. Occupational lung cancer is well documented, as
are COPDs and chronic bronchitis occurring in association with workplace cx-
posures. Occupational asthma is now increasingly common, with the list of sub-
stances known to be capable of causing asthma growing rapidly. Chapter 10 pro-
files the common occupational lung diseases.

For many people, the distinction between the work environment, the home,
and the general environment is an artificial distinction, as discussed in Chapter 1.
Exposure control in the community should always be linked to exposure control
inside the plant, and the fact that exposures are usually much higher inside the
plant should always be taken into account in prioritizing prevention activities.
AIR POLLUTION AND THE COMMUNITY
Magnitude and Sources of Ambient Air Pollution

Industrial development has been associated with the emission to air of large quan-
tities of gaseous and particulate emissions from both industrial production and
burning of fossil fuels for energy and transportation. When technology was in-
troduced to control air pollution by reducing emissions of particles, the problem
was much improved but it was found that the gaseous emissions continued and
the fine particles that are still generated caused problems of their own. Current
efforts to control both particulate and gaseous emissions have been generally suc-
cessful in much of the developed world, but air pollution remains a health risk
even under these relatively favorable conditicns.
In rapidly developing societies, resources are rarely invested in air pollution
control, initially because other economic and social issues took priority. The rapid
expansion of industry in these countries has occurred at the same time as increasing
automotive traffic, increasing demands for power for the home, and concentration
of the population in large urban areas called megacities. The result has been some
of the worst air pollution problems in the world, at levels much higher than those
usually observed in countries where development has already occurred.
Exposure to air pollution is part of urban living throughout the world. Over
the past 20 years there has been a shift in the type of air pollution affecting de-
veloped countries, as the traditional pollutants from stationary sources (such as
SO 2 and suspended particulate matter SPM]) have been effectively controlled
by the implementation and enforcement of legislation in many developed coun-
tries. Also, a change from domestic coal burning to electricity and natural gas for
heating and cooking purposes has lead to a lower level of emissions of SO 2 and
SPM with a concomitant improvement in air quality. However, further economic
development (and increasing personal wealth) has resulted in increases in in-
dustrial emissions and especially in motor vehicle traffic. This in turn has led to
increases in pollutants associated with motor vehicle transport, most notably NOR ,
CO, and hydrocarbons, as well as ozone and other photochemical oxidants and
lead in many jurisdictions. Attempts to control emissions, primarily through the
introduction of catalytic converters and more fuel-efficient engines, have largely
been outstripped by growth in motor vehicle traffic (see Mage and Zali, 1992).
Meanwhile, in many developing countries, rapid urbanization has resulted in a
duplication of many of the problems faced by developed countries. In certain
countries, heavy reliance on coal and oil for fuel means that urban SO 2 and SPM
levels remain high. In addition, rapid economic development has meant that
emissions from industry and motor vehicles are increasingly causing air quality
problems (Table 5.7). These issues are discussed further in Chapters 8 and 9.
AIR 201
TABLE 5.7
RELATIVE CONTRIBUTION OF DIFFERENT EMISSIONS AND RESPECTIVE
POLLUTANTS IN SÃO PAULO, BRAZIL
Particulate Matter Sulfur Oxides Carbon Monoxide Nitrogen Oxides
(%) (%) (%) (%)
Vehicles 40 64 94 92
Industry 10 36 3 7
Other 50 0 3 1
Source: Stephens et al., 1995.
Urban air pollution at extremely high levels is implicated in acute and chronic
lung diseases, heart disease, and neurological damage. In the past decade, some
of the highest air pollution levels (for SO 2 ) have been found in cities in devel-
oping countries (seven of the world's ten worse cities were in developing coun-
tries). Today, the worst megacitics for SO 2 pollution are in developing countries.
More than a billion people live in urban areas with unacceptable air quality con-
ditions. Some of the most severe situations of air pollution are in these mega-
cities, such as Mexico City and São Paulo (Brazil).
Ambient Air Quality Standards and Guidelines

Some air pollution problenis, such as foul odors, can be dealt with as a public
nuisance. Industrial and urban air pollution is more complicated, and effective
control requires (a) identifying and measuring the pollutants that are most re-
sponsible for the problem and (b) reducing or preventing their emission at the
source. Control of air pollution requires the identification and control of indi-
vidual sources of emissions to air to prevent the accumulation of air pollution in
a certain region, or airshed. An airshed is a space, such as a valley, basin, or plain,
within which air mixes relatively freely but beyond which movement is rela-
tively slower, and typically depends on winds. To improve air quality within an
airshed it is necessary to control all the sources within the airshed.
To set targets for the control of air pollution, it is necessary to set standards
or guidelines. The word standard implies a set of laws or regulations that limit al-
lowable emissions or that do not permit degradation (deterioration) of air qual-
ity beyond a certain limit. The word guidelines implies a set of recommended lev-
els against which to compare air quality from one region to another over time.
Table 5.8 presents the standards developed by the U.S. Environmental Protec-
tion Agency (USEPA) for the United States. Table 5.9 presents the revised air
quality guidelines for Europe recommended by the WHO for "classical" air pol-
lutants. Two additional lists exist for specific air toxics, one for carcinogens and
one for chemicals that are not carcinogenic (WHO, 1998).
Standards may take two forms: ambient air quality standards and emissions
standards. Ambient air quality is the general quality of outdoor air in the region.
Guidelines are usually for ambient air quality only. Emissions standards set the
amount of pollution that is allowed to come from a particular source (see Chap-
ter 4). Ambient air quality standards or guidelines are levels of general air quality

TABlE 5.8
AIR QUALITY STANDARDS, UNITED STATES, 1989
Pollutant Primary Standards Average Time Health Effects
Carbon 9 ppm (10 nig/ni) 8 hr Aggravation of coronary artery
Monoxide 35 ppin (40 mg/in 1 ) 1 hr disease
Lead 1.5 jaglm t Quarterly average Development effects no children
NO2 0053 ppm (100 p_g/m t ) Annual (arithmetic Increased respiratory infections,
mean) risk of acute lung disease
Ozone 0.12 ppm (235 /Lgf in) 1 hr Decrements in lung junction,

possibly chronic lutig disease
PNI to 150 Aghr0 24 hr Chronic respiratory disease,

50 geglm 1 Annual (arithmetic altered lung function in
mean) children, increased mortality
SO2 0.14 ppm (365 /ag/11 1 ( 24 hr Exacerbation of asthma

0.03 ppm (80 fag/n)') Antival (arithntetic
mean
in the region that the jurisdiction responsible cannot allow to be exceeded. Some-
times the penalty for this is withholding of funds from the national government
or some administrative penalty. Ambient air quality is monitored in various places
within the region; an exceedance occurs when the level of a particular pollutant is
exceeded. The number of exceedanccs, the average levels of air pollution, and the
peak levels during 1 hr may all be used as indicators in air quality standards or
guidelines. Ambient air quality standards may include a nondegradation policy, which
TABLE 5.9
WHO AIR QUALITY GUIDELINES FOR EUROPE, REVISED 1999
Compound Guideline Value Averaging Time
Carbon motinxide 1 ' 100 tng/m 1 (90 ppm) 5 15 mm
60 mg/m 1 (50 PP°')" 30 mm
30 mg/ni 1 (25 ppm) 1 hr
10 mg/m 1 (10 pPt)1) 8 hr
Lcad 0.5 p,g/111 1 n.a. 1 year
Ozone 120 fag/rrt 1 (0.06 ppm) 8 hr
Particulate matter" na. na.' na.
Nitrogen dioxide 200 fag/n1 3 (0.11 ppm) 1 hr

40 fag/m 3 (0.021 ppm) Annual
Sulfur dioxide 500 fag/rn 1 (0.175 ppm) 10 miii

125 gtg/m 1 (0.044 ppm) 24 hr
50 Lg/111 3 (0.017 ppm) Annual
'Nil guideline values were set br particulate matter because there is no evident threshold for effects on mor-
bidity and mortality. Authorities are referred to risk estimates for particulate concentrations on the WHO website.
'The guideline is to prevent COHb levels in the blood from exceeding 2.5%. The values above are mnathe-
mnamical est umates of CO concentrations and averaging times at which these concentrations should be achieved.
'Critical level of lead in blood: <tOO to 150 ag/lmtre.
11.11. = not applicable.
Source: WHO, 1999.
AIR 203
means that not only should air pollution not exceed certain levels but it cannot be
permitted, on average, to get worse over time even within the allowable levels.
Central of Ambient Air Pollution

Control of emissions at each source is the key to managing air quality, but trans-
portation policy, energy policy (such as the choice of fuels), and siting of facilities
that may emit pollution all play a critical role. A major element in the success of
air pollution control is the degree of authority that can be exerted by the govern-
ment agency that has this responsibility. The ability to close or shut down a plant
is the ultimate tool for enforcement agencies, but the ability to fine, bring lawsuits,
and prosecute offenders is just as important. Often just the threat of such action
motivates the management of a plant to cooperate and correct the problem.
Emissions standards (rules about how much pollution a particular source may
emit to the atmosphere) require periodic inspection and regular monitoring to
be effective. These are generally easier to enforce for stationary sources, where
equipment can be set up on a permanent basis and the pollution control appa-
ratus can be inspected directly. The source or facility may require a permit from
the government to operate or may be required to register and to provide regu-
lar reports on the pollution it has generated.
Generally, emissions standards for individual factories, power plants, or other
stationary sources allocate an allowable level of emissions based on their past
performance and share of contribution to the regional airshed. They must not
exceed this allowable level of emissions or they will receive a citation and must
pay a fine. (In practice, the fine must be high enough to deter violations and not
be just another cost of doing business.) If they are repeat violators, their permit
to operate can be suspended if the law allows.
In some jurisdictions, the entire plant is considered a single source for pur-
poses of regulation; if engineers can reduce emissions in one part of the plant,
they are allowed to build new facilities that increase emissions in another part
or to build a new addition to the plant that may generate new emissions. The
overall level of emissions from the entire plant must not increase, however. This
is called the bubble concept, because the plant is thought of as being enclosed in
a bubble and the air quality in the bubble cannot be allowed to deteriorate.
Mobile sources are more difficult to monitor, however, and many jurisdic-
tions require regular vehicle inspections to ensure that emissions from each truck
or automobile are within acceptable limits (see Mage and Zali, 1992). Box 5.3
summarizes some strategies to address motor vehicle air pollution.
To effectively tnanage air quality in an urban region, an administrative mech-
anism must be set up that includes trained inspectors and technical staff who can
operate the complicated equipment needed for air quality monitoring and who
can interpret the results. A permitting or registration system is needed for en-
forcing emissions standards. Public education should be very much a part of the
duties of the staff, as should enforcement and monitoring. Many air quality agen-
cies are operated separately from public health agencies, which are often attached
to the environmental departments of government. Ideally, these agencies have
the authority to meet with plant owners or managers before facilities are even
built to avoid problems before they occur.

pox c,
Motor Vehicle Air Pollution: Control Strategies
Studies of human exposures to air pollutants from motor vehicles have revealed the
following:
• Concentrations of some air pollutants inside motor vehicles and along roadsides
are typically higher than those recorded simultaneously at fixed-site monitors.
• Exposures tend to be higher inside automobiles than in buses and other vehicles
used in public transit.
• Priority lanes used to afford speed advantages to buses and car pools tend to re-
duce air pollutant exposures.
• Concentrations of air pollutants in enclosed settings are similar to outdoor con-
centrations in the absence of indoor sources, but tend to lag behind the peak con-
centrations observed outdoors. (A notable exception is commercial buildings at-
tached to inadequately ventilated parking garages.)
• Concentrations of motor vehicle air Pollutants decline with greater distance from
the road, suggesting that passengers and vehicles are at greatest risk, followed by
pedestrians and street merchants along roadsides, and then the general urban pop-
ulation.
Motor vehicle emissions may be reduced by (1) controlling vehicle performance,

and (2) altering fuel composition. With respect to vehicle performance, this can be
controlled by ensuring that vehicles are designed and built to meet standards. It is
also necessary that they be properly maintained. Proper maintenance, in turn, can
be promoted by providing incentives to car owners to obtain proper maintenance
and by using marketplace incentives. Requiring maintenance through a mandatory
inspection and maintenance program is considered by many to be the most effec-
tive incentive for car owners.
Control of fuel composition is a direct means of controlling emissions, e.g., re-
ducing the lead content in leaded gasoline or reducing sulfur content to control sul-
fate emissions. Studies suggest that gasoline hydrocarbon emissions decrease signif-
icantly with lower fuel sulfur. Control of gasoline volatility is another strategy for
reducing vehicle evaporative and refueling emissions, especially in areas with
warmer climates. Some additives have been effective in lowering hydrocarbon emis-
sions and carbon monoxide.
Reduction of emissions per vehicle rriile traveled can he very effective in con-
trolling emissions. Strategies for emission reduction include car pooling, increased
use of mass transit, parking restrictions, and gas rationing. Policies would therefore
be needed to create more efficient public transportation systems; increase the load
factor of existing vehicles; shift time of peak traffic (e.g., staggering work hours);
improve circulation through use of synchronized signals, and reduce travel demand,
e.g., by redistribution of urban activities. Chapter 8 presents some examples of suc-
cesses regarding bicycle use.
Source: Maqe and Zali, 1992.
AIR 205
200
150
• 2 100
1)
0
C
0
0
50
0
(I)
1977 1979 1981 1983 1985 1987 1989
Figure 5.7 Trends in sulfur dioxide concentrations in selected cities around the world.
Froin UNEP, 1992a, with permission.
Due to growing public concern, many nations initiated air quality monitor-
ing in the 1960s. In 1973, the WHO set up a global program to assist countries
in operational air pollution monitoring. This project, which became a part of
UNEP's Global Environmental Monitoring System in 1976, covers some 50 coun-
tries, and data from this project suggest that nearly 900 million people living in
urban areas around the world are exposed to unhealthy levels of SO 2 and more
than one billion people are exposed to excessive levels of particulate matter (see
Figure 5.7 for trends in SO 2 concentrations in selected cities around the world).
Indoor Air Pollution

Indoor air pollution has been identified as one of the foremost global environ-
mental problems (World Bank, 1993). This source probably exposes more peo-
ple worldwide to important air pollutants than pollution in outdoor air, as dis-
cussed in Chapter 9. Whereas outdoor air in such cities as Delhi, India, or Xi'an,
China contains a daily average of 500 rgIm 3 of SPM, smoke inside houses in
Nepal and Papua New Guinea contains a daily average of 10,000 ig/ni 3 or more.
An SPM level of 50-100 .rg/m 3 may cause adverse health effects (WHO, 1987a).
Rural people in developing countries may receive as much as two-thirds of the
global exposure to particulates. Women and young children suffer the greatest
exposure.
Inefficient and smoky fuels burned for cooking and heating are a source of
serious air pollution in many traditional and developing societies. The use of such
fuels causes problems both indoors and outdoors. In homes where open fires
burn, especially when the climate is cold, the pollution from the fires accumu-
lates and exposes the inhabitants, especially women, to the risks associated with
smoke inhalation. The result can be serious lung disease and an increased risk
of cancer, as occurs in some parts of China among women who tend fires in
homes heated with coal.
The quality of air indoors is a problem in many buildings in developed coun-
tries because they were built to be airtight and energy efficient. Chemicals from
burning fuels, smoking, and other sources in the building accumulate and crc-

ate pollution. The most important indoor air contaminants in developed coun-
tries are tobacco smoke, radon decay products, formaldehyde, asbestos fibers,
combustion products (such as NOR, SO,, CO. CO 2. and polycyclic aromatic hy-
drocarbons), and other chemicals used in the household. Tobacco smoke is a pri-
mary contributor to respirable particle exposures indoors. In the United States,
concentrations of about 50 tkglml in houses with smokers and about 500 igIm 3
in smoky bars have been recorded (Brooks et al., 1995). Several microbiological
air contaminants also cause indoor air pollution, including molds and fungi,
viruses, bacteria, algae, pollen, spores, and their derivatives. In airtight buildings
especially (e.g., buildings that are energy efficient, but with poor ventilation), in-
door air pollutants can accumulate, causing "sick building" syndrome. This is dis-
cussed further in Chapter 8.
Indoor air pollution contributes to acute respiratory infections in young chil-
dren, exacerbation of asthma, chronic lung disease and cancer in adults, and ad-
verse pregnancy outcomes for women exposed during pregnancy. Acute respi-
ratory infections, principally pneumonia, are the chief killers of young children,
causing a loss of 119 million disability-adjusted life years (DALYS) per year, or
10% of the total burden of disease in developing countries (World Bank, 1993).
The World Bank estimates that smoky indoor air, largely from biomass fuel for
cooking or heating, contribute to the acute respiratory infections that kill 4 mil-
lion people a year, again mostly children under age 5.
uestions
Draw a diagram showing how the physical forms are related and how sub-
stances may change from one form to another.
Describe the specific composition of particulates and gaseous constituents
of (1) wood smoke, (2) cigarette smoke, (3) automobile exhaust, and (4) emis-
sions from a coal-fired power plant. Which has the most matter? Which is pre-
dominantly gas? Which is most complicated chemically? Which is likely to be
most dangerous?
Is air pollution a problem in your area? What are the main sources? What
control measures are being used to reduce air pollution at the source? along the
path? at the level of the person?
How have criteria for developing air quality been developed? What are the
scientific and nonscientific issues in setting standards for air quality?
Air quality management may involve controlling sources of emissions from
industry, transportation, and homes. What effect on air quality may be expected
from a national transportation policy that favors automotive transportation over
mass transit? What may be expected from a national energy policy that favors
the burning of fossil fuels over hydroelectric or nuclear energy? Does the eco-
nomic base and structure of the community have any implications for air qual-
ity in the region? What role does city and regional planning play in influencing
air quality? Use your home community as an example of these issues, then com-
pare the situation in another city, town, or village in your country. A number
AIR 207
of initiatives and suggestions for better management of air resources have been
discussed in this chapter. Try to develop other initiatives that could be used to
promote air quality conservation—these could be economic, social, legal, or phys-
ical in nature. (Chapter 8 will return to the issue of air quality as it relates to ur-
banization; Chapter 9 will discuss it with respect to energy policy; and Chapter
10 will discuss it with respect to industry.)
6. Is indoor air pollution a problem in your home? What are the main sources?
How do you maintain air quality?

! 01F-
WATER AND SANITATION

LEARNING OBJECTIVES

• discuss the importance of clean water as a determinant of health and dis-
cuss the nature and extent of wuterborne diseases
• list the major sources of water contamination
• discuss how drinking-water criteria are developed
• outline the various approaches to prevention of water-related environ-
mental health problems and the debates associated with implementation
strategies
CHAPTFP. CONTENTS
Why Water is Essential Acceptable Daily Intake and
Water Quality, Sanitation, and Health Guideline Values for Chemicals
Communicable Diseases Associated Drinking-Water Supply and Monitoring
with Water The Source
Chemical and Radioactive Con- Treatment of Drinking water
stituents of Water Distribution and Storage
Other Aspects of Water Quality Place of Use
Adequacy of Freshwater Supply to Sanitation
Meet the World's Needs Control of Water Pollution
Adequacy of Supply Industrial Pollution
Global Trends Wastewater Treatment and Reuse
Determining Quality of Fresh
Recreational Water Quality Guidelines
Water
Ensuring a Safe and Sufficient
Drinking -Water Quality Criteria
Water Supply
Monitoring Contaminants
The Water Decade, 1981-1990
Microbiological Standards
Water Resources Management
WHY ATERISSSENTIAT
Water (or liquids based on water) is essential for basic survival (see Chapter 1).
When a person has nothing else to drink, even poor-quality water must be con-
sumed to stave off death through dehydration. The relief may only be tempo-
rary since contaminated water can spread disease and cause poisoning. People
209
and animals drink water but they also bathe in it and depend on it to grow crops.
Every person on earth requires about 2 liters of clean drinking water each day,
which amounts to 12 million m 3 /day for the world's population. Animal con-
sumption is considerably larger, but animals do not require the same quality of
water needed for human consumption. Most of the world's fresh water is used
for irrigation: 70% of fresh water is used daily. As the world population increases,
the demand for drinking water and irrigation will grow. Water is also used in
the generation of hydroelectric and thermoelectric power. Dammed reservoirs
provide the gravity-driven force that turns turbines to produce electricity (ener-
gize dynamos). Water also acts as a coolant for nuclear and coal/oil power sta-
tions. Industry uses significant amounts of water, particularly in the production
of paper, petroleum, chemicals, and primary metals. Attempts have been made
in these industries to cut back on water consumption through reuse of water, as
well as through new processing methods. Water is used for the transportation of
goods and people, as a means of recreation through swimming and boating, and
as a natural habitat for many forms of fish and wildlife. Seawater is also used to
produce salt. The quality requirements for different water uses vary and the im-
pact on water quality varies with the type of use (see Box 6.1).
This chapter will emphasize the health hazards related to contaminated drink-
ing water and lack of proper sanitation. Lack of good-quality water is a key prob-
lem in economic development in many parts of the world. In dry parts of the
world, lack of water sources is complicated by the poor quality of what is avail-
able. The term water privation diseases comprises those health problems that oc-
cur because of lack of water.
WATER QUALITY, SANITATION, AND HEALTH
Coirnunicable Diseases Associated with Water

Bacteria, viruses, and parasites can spread by water and cause disease. These
agents of disease are called pathogens. Most of these diseases are considered com-
municable because they can spread from one person to another via contaminated
water or other vectors. The water is a vehicle for spread of the pathogens and
other environmental health hazards. The most common diseases of this type are
diarrheal diseases, such as cholera, typhoid, paratyphoid, salmonella, giardiasis,
and cryptosporidiosis (Box 6.2; see Chapter 2). The minimal infectious dose (the
number of bacteria required to make a person ill) is much lower for cholera than
for the other diseases, so cholera can spread even via water that looks reason-
ably clean. The feces of an ill person with cholera or carrier contain large num-
bers of pathogenic organisms and the contamination of drinking water by feces
creates the opportunity for spread of the disease to another person. Many of the
communicable diseases that spread via water can also spread via food (see Chap-
ter 7). Successful prevention would have to address both exposure routes. A per -
son does not even need to drink the water to get diseases associated with it. In
schistosomiasis, a parasitic tropical disease, for instance, the parasite enters the
human body through the skin and causes disease after being transported inside
the body to the target organs—the gut and the urinary bladder (Box 6.2).

BOX 6.1
Water Use and Water Quality
Uses affecting waler quality:
Municipal sewage discharge, storm water run-off

• Agricultural manure disposal, agrochemicals, drainage water discharge
• Industrial wastewater effluents, cooling water discharge, acid mine drainage
Uses limited by water quality:
• Municipal drinking, domestic and public uses

• Agricultural domestic farm supply, livestock watering, irrigation
• Industrial food and other processing, boiler feeding, cooling, mining
• Recreational swimming and other water-contact sports, aesthetic enjoyment,
fishing
• Aquatic life aquatic and wildlife, fish, swamp and wetland habitat, aquaculture
Uses less or not at all affected by water quality, and with usually less impact on wa-
ter quality:
• Commercial hydropower generation, navigation

• Recreational boating, landscape watering
Source: WHO/UNEP, 1989.
A flowing body of water partially cleans itself. Dissolved oxygen, clay and soil
particles, and living organisms in the water all play an important role in the
process. Flowing water can dilute, oxidize, and remove pathogens as long as its
capacity is not exceeded and sufficient time elapses before water is withdrawn
downstream for human use. When the population density of a given area places
intense pressure on water resources, this self-purifying capability of water is ex-
ceeded. Bodies of water that have their natural flowing properties removed, as,
for example, through damming, are much less able to cleanse themselves.
According to Agenda 21, the United Nations Program of Action from the Rio
Conference in 1992 (UN, 1993), 80% of all diseases and over one-third of deaths
in developing countries are caused by consumption of contaminated water. As
much as one-tenth of every person's productive time is sacrificed to water-
related diseases (UN, 1993). An estimated 1.4 billion people still do not have ac-
cess to safe drinking waler and 2.9 billion do not have access to adequate sani-
tation (UN 1997), and according to the World Resources Institute (WRI, 1998)
this inadequate access to water and sanitation contribute to 2.5 million child-
hood deaths each year from diarrhea. Most pathogens come from animal or hu-
man feces, a result of insanitary excreta disposal. Inadequate water supply plays
an equally important role in the spread of disease. Most diseases that are water-
WATER AND SANITATION 211

BOX 6,2
Three Diseases Associated with Water
Cryptospondwsis is a diarrheal disease caused by the protozoan Cryptosporidium parvurn.

As a result of a number of waterborne outbreaks of cryptosporidiosis in developed
countries in the last 5 to 10 years (such as one in Milwaukee, Wisconsin, USA, in
1993, in which 400,000 people fell ill and 100 died), there has been renewed in-
terest in the epidemiology of this emerging infectious disease. While much is still
not known about this microorganisni, waterborne transmission and person-to-
person transmission may play an important role. For most healthy persons, infec-
tion leads to self-limiting watery diarrhea with or without nausea, vomiting, and
abdominal cramping. Symptoms may last I to 2 weeks. However, immunocompro-
mised people, those with AIDS, on immunosuppressant drugs, or vulnerable oth-
erwise, may not he able to fight the infection. Cryptosporidiosis may represent a
lethal disease to this population.
Schistosomiasis, otherwise known as snail fever, or hilharzia, is an infection caused
by a blood fluke (trematode). Major species infecting humans include Schistosoma
mansoni, S. japonicum, and S. haematobium. Infection is acquired by contact with wa-
ter containing cercariae, the free-swimming larval form that has developed in snails.
The cercariae burrow into the skiii of susceptible hosts, enter the bloodstream, mi-
grate to the liver, and ultimately reside in veins of the abdominal cavity. The adult
male and female worms can reside in the mesenteric or vesical veins of the host for
many years. Signs and symptoms are to a certain degree related to the species of
infecting worm, but may include bloody urine, abdominal pain, or diarrhea. The
larvae of certain schistosomes of birds and mammals may penetrate the human skin
and cause a dermatitis, sometimes known as swimmers itch. These schistosomes, how-
ever, do not mature in humans and therefore do not cause serious disease.
Giardiasis is a protozoan infection caused principally by Giardia lamblia, G. in-
t€'stinalis. or C. duodenalis. While often asymptomatic, infection may cause abdomi-
nal cramping, diarrhea, fatigue, and weight loss. Inlection may be acquired by in-
gestion of fecally contaminated food or water, or by hand-to-mouth transfer of cysts
from the feces of infected people. See Chapter 7 for additional inlormation.
Sources: Meinliardt et al., 1996; Benenson, 1995.
borne may also be transmitted by person-to-person contact, aerosols, and food

intake; thus, a reservoir of the bacteria is maintained in the people carrying the
disease and a sick individual may contaminate water or food supplies and thus
continue disease transmission (WHO, 1993a). Some people get infected but do
not get the disease symptoms. These people may become carriers of the disease.
One of the most famous carriers, known as "Typhoid Mary," lived in New York
(Federspiel, 1983). An Irish immigrant who was infected with typhoid around
1900 but did not become ill herself. Instead she became a carrier of the disease
because the bacteria lodged permanently in her gallbladder and constantly passed
into her gastrointestinal tract. Mary, a kind and well-liked woman, repeatedly

took jobs as a food preparer because she did not believe that she could spread
disease. By the time she was put in permanent custody by public health au-
thorities in 1915, she had infected at least 47 people and three had died. At the
time, it has been estimated that there were at least 200 such carriers in New York
City alone!
Most diseases associated with water are caused by pathogens. These diseases
are traditionally classified according to the nature of the pathogen. However, such
a classification is not very useful for prevention. As explained in Our Planet, Our
Health (WHO, 1 992a), a more useful way of classifying these diseases is accord-
ing to the various aspects of the environment that human intervention can al-
ter, hence this classification will be used here.
Waterborne Diseases These arise from the contamination of water by human or

animal feces or urine infected by pathogenic viruses or bacteria, which are di-
rectly transmitted when the water is drunk or used in the preparation of food.
Cholera (see Box 6.3), typhoid, and cryptosporidiosis are typical examples of Wa-
terhorne diseases.
Water-Privation Diseases This category of diseases is affected more by the quan-

tity of water rather than by quality. These diseases spread through direct contact
with infected people or materials contaminated with the infectious agent. Infre-
quent washing and inadequate personal hygiene are the main factors in these
types of diseases, such as certain types of diarrheal diseases, helminths, and skin
and eye infections.
Water-Based Diseases In these diseases, water provides the habitat for interme-
diate host organisms in which some parasites pass part of their life cycle. These
parasites are later the cause of disease in people as their infective larval forms in
fresh water find their way back to humans, either by boring through wet skin
or by being ingested with water plants, minute water crustacea, or raw or inad-
equately cooked fish. Schistosomiasis is an example of a water-based disease.
Water-Related Diseases Water may provide a habitat for insect vectors of water-
related diseases. Mosquitoes breed in water and the adult mosquitoes may trans-
mit parasite diseases, such as malaria, and virus infections, such as dengue, yel-
low fever, and Japanese encephalitis.
Water-Dispersed Infections The disease categories listed above are primarily prob-
lems in developing countries. A fifth category of diseases associated with water
is emerging in developed countries—infections whose pathogens can proliferate
in freshwater and enter the body through the respiratory tract. Some freshwa-
ter amoebae that are not usually pathogenic can proliferate in warm water, and
if they enter the host in large numbers, they can invade the body along the ol-
factory tracts and cause fatal meningitis. These bacteria can be dispersed as
aerosols from air-conditioning systems; an example of this type of disease is Le-
gionella (WHO, 1992a).

BOX 6.3
Latin American Cholera Epidemic
Cholera is one of humankind's oldest diseases and one of the best-known water-
borne diseases. Drinking water that has been contaminated at the source or during
storage is the most common source of infection. Any foods that have been taken
from contaminated water (fish, shellfish) or washed with it (fruit, vegetables) are
also important sources of infection. Severe diarrhea and vomiting are the main symp-
toms of cholera. The diarrhea is so severe and rapid that patients suffer severe loss
of liquid. The main treatment is therefore intravenous or oral liquid rehydration,
which prevents the patient from becoming fatally dehydrated. About 90% of cholera
cases are mild and difficult to distinguish clinically from other types of acute diar-
rhea.
The first cholera epidemic in Latin America since the turn of the century began
in Peru and quickly spread to a number of neighboring Latin American countries,
spreading as far north as the United States. Peru was hardest hit by the disease with
a total of close to 300,000 cases reported by January 1992. The spread of disease
during the initial period, by February 1992, and by March 1993, is shown in Fig-
ure 6.1.
In assessing what had led to the devastating cholera outbreak in Peru, a num-
ber of factors were identified: (a) urban water supplies were operated on an inter-
mittent basis and thus subject to contamination from leaks, back siphoning, and
* Initial epidemics
January 1991
- August 1991
- February 1992
March 1993
00
Figure 6.1 Geographic extent of the Latin American cholera epidemic over time.
From Hug and Colwell. 1996, with permission. continued)

(cOfltlnu'd)
cross connections; (b) most households had inadequate hygiene practices related to
water storage; (c) in periurban areas most households were not connected to the
piped water or sewage systems; (d) organized garbage and solid waste storage, col-
lection, and disposal were nonexistent in the periurban areas and inadequate in
many of areas of the central city; and (e) among the poor, fundamental health and
sanitation practices were often not applied. A WHO document released following
the outbreak outlined a number of guidelines for controlling cholera. These include
providing a safe water supply, properly disposing of human waste and educating
communities about how to prepare safe water at home (WHO, 1993b).
Chemical and Radioactive Constituents of Water

Some chemical substances dissolved in water as a result of natural processes may
be essential ingredients of dietary intake, and some may be dangerous to health
when they occur above certain concentrations. Others have both properties si-
multaneously. To assess the health impact of all of these substances, the Global
Environment Monitoring System (GEMS), discussed further in Drinking-Water
Supply and Monitoring (below), classifies chemicals in drinking water into three
typical categories:
Substances (various metals, nitrates, cyanides) that exert an acute and/or
chronic toxicity when consumed. As the concentration of these substances in the
drinking water increases, so does the severity of the health problem; below a cer-
tain threshold concentration, however, there are no observable health effects.
Genotoxic substances (synthetic organics, many chlorinated microorgan-
ics, some pesticides, and arsenic) that cause adverse health effects such as car-
cinogenicity, mutagenicity, and birth defects. There is no threshold level for these
substances that would be considered safe, since any amount ingested contributes
to an increase in risk.
Essential elements (fluoride, iodine, selenium) that are a mandatory part
of dietary intake to sustain human health. Deficiencies or high concentrations of
these elements cause a variety of adverse health effects (WHO/UNEP. 1989).
Some chemicals present in water are of particular importance with regard to
their effect on human health. These include arsenic, fluoride, iodine, and nitrates.
Arsenic Arsenic is naturally ljresent in all lead, copper, and gold ores. Ground-
water enriched through the weathering of arsenic-bearing minerals is generally
the most important source of arsenic in drinking water. There are several geo-
logical areas in Asia, North America, and Latin America where derinatological
effects were the first manifestation of groundwater enrichment of arsenic. At
chronic poisoning levels, various effects are observed, such as vascular disease,
liver disease, skin lesions, skin cancer, and neurological disorders.
Fluoride Fluoride is naturally present in some foods as well as in water, but for
the most part, it is the amount provided by drinking water that determines the
daily intake. Since fluoride is an important component in bone and tooth struc-
ture, it is considered an essential element. It is also a toxic chemical. Only a mel-

atively narrow range of fluoride concentrations in drinking water provides opti-
mal conditions. Too-low levels of fluoride increase the incidence of dental caries
whereas elevated levels cause mottling of the teeth as well as skeletal fluorosis.
Fluoride is added to drinking water in some countries to improve dental health.
Iodine Water is one of the main sources of dietary intake of iodine. In areas
where there is very low concentration of groundwater iodine, resident popula-
tions suffer from iodine deficiencies resulting in an enlargement of the thyroid
gland (goiter) and, in severe cases, mental retardation and cretinism.
Nitrates Excessive and widespread application of nitrogenous fertilizers and ma-

nure spraying are the main sources of elevated nitrate concentrations in ground-
water. High levels of nitrates in drinking water are of concern because they may
lead to serious, even fatal consequences in infants below 6 months of age. Ni-
trates are reduced to nitrites and, once absorbed, combine with hemcglohin to
form methaemoglobin, which is unable to bind with oxygen and therefore trans-
port it from the lungs to the tissues (WHO/UNEP, 1989). The nitrate concentra-
tion in selected river systems is shown in Figure 6.2 (WHO, 1992a). With time
there is an apparent increase in concentration in many of these rivers.
Other Aspects of Water Quality

Color The color of drinking water is usually due to the presence of colored or-
ganic matter associated with the humus fraction of soil. Color is influenced by
the presence of iron (usually rusty brown) and other metals—this may be caused
E;3
U,
- 6
z
0)
E
C
0
C
a)
0
C
0
(-)
a, 2
CU
a, CU
z 0
Measured at mouth or downstream frontier of rivers
Figure 6.2 Nitrate concentrations in selected rivers: 1970, 1975, 1980, and late 1980s.
From WHO, 1992a, with permission.

by natural impurities or may be a signal of corrosion products. It may also result
from the contamination of the source with industrial effluents, which could in-
dicate a hazardous situation.
Taste and Odor Taste and odor originate from natural and biological sources,
from contamination by chemicals, or as a side effect of water disinfection. Taste
and odor may develop during storage and/or distribution. Any deviations in taste
and odor may indicate some sort of pollution or malfunction with the storage or
distribution systems.
Temperature The temperature at which water is consumed is very much a mat-

ter of personal preference. Generally, cool water is more palatable than warm
water. High-temperature water enhances the growth of microorganisms and may
increase taste, odor, color and corrosion problems.
Turbidity Turbidity in water is caused by particulate matter that may he present

as a consequence of inadequate treatment or the presence of inorganic particu-
late matter in some groundwater. High turbidity levels can protect microorgan-
isms from the effects of disinfection and can stimulate bacterial growth.
Although deviations in the physical characteristics of drinking water may be
harmless, any significant changes over time should be investigated, as these may
indicate potentially hazardous situations.
ADEQUACY OF FRESHWATER SUPPLY TO MEET

THE WC)R! D'S NFFDS
Adequacy of Supply
Freshwater quality and quantity are inextricably linked. There is sufficient fresh-
water worldwide to meet human demands at present and in the foreseeable fu-
ture, but because of uneven distribution of groundwater, surface water, and rain-
fall, many and and semi-arid parts of the world lack reliable sources. Of all the
world's water, 97% is in oceans or lakes. Of the remaining 2.53 0%. by far the
largest part, 69%, is in the form of snow and ice. The available liquid fresh sur-
face water upon which most communities depend accounts for only 0.008
(2.53% X 0.34) (see Fig. 6.3).
Sources of freshwater include rivers, lakes, and groundwater. The last three
centuries have witnessed a significant growth in the volume of water being with-
drawn from these sources, an increase of more than 35 times compared to a sev-
enfold increase of the population. In recent decades, there has been a further in-
crease in water withdrawal, with the highest rates of growth occurring in
developing countries. The main increase in water withdrawal is for agricultural
purposes (see Fig. 6.4).
Access to water is at least as important a problem for health as water contam-
ination. Water is distributed very unevenly around the world and those areas
with less access have had much greater problems with hygiene and quality of
water. The tropics and the mid-level of the Northern Hemisphere has much more
potential freshwater available than other parts of the world.

Total Water Resources Freshwater Reserves
World's Oceans / Glaciers and Permanent

96.50% / Snow Cover
I 68.70%
Rivers,
Lakes,
Swamps
Permafrost and Other
Freshwater 0.86% 0.34%
Other Reserves Groundwater
0.97% 2.53% 30.1%
Figure 6.3 Global total water and freshwater reserves. From Shiklomanov, 1993, with
permission.
Countries are not simply water-rich or water-poor; there is wide variation

within many countries. Calculations based on the level of precipitation per unit of
area, for example, are very misleading. Users of water upstream may affect the
quality of water available to users downstream. Many countries draw water for
sources that come from the territory of other countries, e.g., as Egypt does with
the Nile, and The Netherlands does with the Rhine. In the case of Egypt, river in-
flow provides 50 times more water than does rainfall. The intensity with which
local river runoff is used may be a more revealing indicator of water scarcity.
Global Trends
The issue of water scarcity carries many political, legal, and economic implica-
tions. Many of the important water basins of the world are shared by more than
one country, as in the Great Lakes of Africa and the Aral Sea. The Aral is badly
depleted and contaminated on both the Kazakhstan and Uzhekistan sides. It draws
3,500
3,000 Agriculture
• 1
2,500
/
• 1
2,000
/
. 1,500 Industry
0
1,000 I-
/ Domestic
500 Municipa
Figure 6.4 Global water with-
0 drawal by sector, 1900-2000.
1900 1920 1940 1960 1980 2000 From Shiklomanov, 1993,
Year with permission.

its water from Turkmenistan, Tajikistan, and Kyrgistan and was heavily affected
during the days of the Soviet Union by economic decision 10 benefit Russia. The
significance that countries attach to their water resources is reflected in the ex-
istence of over 2000 treaties relating to water basins, such as the Great Lakes
Compact between Canada and the United States. The first modern treaty on joint
environmental management was conducted over the Baltic. In many areas of the
world, agreements on sharing water resources are inadequate or do not exist. An
example is the Nile Waters Agreement of 1959, an Egyptian and Sudanese at-
tempt to distribute the flow of that river that did not take into account the re-
quirements and demands of upstream countries like Ethiopia. Turkey's con-
struction of a system of dams on the Euphrates River is expected to reduce inflow
of water to Iraq to as little as 10% of normal flow (WRI, 1994).
Conflict over shared water resources is a reality in many parts of the world.
Attempts in Ethiopia to enhance the flow of the White Nile by building a canal
to bypass the Sued (a large swamp in Southern Sudan) was one factor that be-
gan the civil war in The Sudan. Dispute over control of the headwater of the Jor-
dan River (a basin shared by Syria, Jordan, Lebanon, and Israel) and the possi-
bility that the river might be diverted into the Israeli National Water Carrier
helped to spark the 1967 Arab—Israeli war. Danger of conflict continues due to
the competing demands for surface and groundwater in the Jordan River basin.
Water sharing agreements are expected to he a key issue in any future Middle
East peace agreement. When Solvakia and Hungary had a dispute over damming
the Danube River, the matter went to the International Court of Justice.
One area that has been seriously affected by water use for irrigation is the
Aral Sea river basin. The large-scale cotton-growing projects established in the
1950s eventually used such large quantities of the water in the rivers Amu-Darja
and Sur-Darja that the influx of water into the sea was less than the evapora-
tion. The size of the Aral Sea has therefore gradually shrunk and this has seri-
ously affected the living environment, the economy, and the health of the re-
gion around this landlocked sea.
Many international development projects have inadvertently affected water
resources and have thereby had a negative impact on both the environment and
the health of the communities they were trying to assist. This has occurred even
though the projects were intended to enhance socioeconomic conditions and the
quality of life. Large dams and water reservoirs that were built in Asia and Africa
for irrigation or hydropower in the 1960s and 1970s have led to disastrous con-
sequences, with increases in the cases of schistosomiasis, malaria, and Japanese
encephalitis. Such projects have even led to the introduction of new diseases in
an area, as in the case of intestinal schistosomiasis introduced into the Senegal
River delta following the construction of the Diama dam.
Determining Quality of Fresh Water

The quality and quantity of water tend to be closely linked. Where water is scarce,
the quality often tends to be poor and the effects of pollution have an even greater
impact because there are no alternatives. Over centuries and particularly over
the last few decades, the natural quality of water in rivers, lakes, and aquifers
has been altered by the impact of various human activities and water uses. Most

pollution problems involving water have evolved gradually over time before they
became apparent and measurable. The four most important sources of water pol-
lution worldwide are sewage, industrial effluents, storm and urban runoff, and
agricultural runoff.
In many developing countries the problem of water pollution has become sim-
ilar to that in developed countries. In the past, pollution in developing countries re-
sulted primarily from domestic sewage. While sewage remains a source of pollu-
tion, the increasing use of pesticides for agriculture and the production of toxic
wastes from industry have increased the complexity of water contamination issues.
Currently, in some developing countries water pollution is due to domestic sewer-
age systems or specific pollutants from industry and it is significantly worse than in
industrialized countries where there has been a longer history of pollution control
activities. Any efforts at the international level to distribute water equitably need
to be matched by efforts to combat the pollution of the various water bodies.
Indirect pollution of water from air is also an important factor in water pol-
lution. Acidification is due to long-distance air pollution from industry and motor
vehicle traffic (see Box 6.4). Eutrophication is due to overloading by nutrients (e.g.,
nitrates and phosphates) from agricultural fertilizers.
Sudden growth of microorganisms in water is called a bloom. Blooms of
Cyanobacteria (blue-green algae) occur in lakes and reservoirs used for potable sup-
ply and can produce different types of toxins. Adverse health effects are known to
be caused by these toxins in drinking water and especially in watering holes for
livestock. The increased incidence of toxic algae blooms is sometimes the result of
pollution, particularly sewage and agricultural runoff, although such blooms can
occur naturally in shallow, nutrient-rich bodies of water. There are insufficient data
at the present time to form recommended guidelines, but there is a clear need to
protect impounded surface-water source from discharges of nutrient-rich effluents.
The problem of maintaining good water quality is particularly acute in urban
areas in developing countries. This effort is hampered by two factors: failure to
enforce pollution controls at the main point sources and inadequacy of sanita-
tion systems and of garbage collection and disposal. Box 6.5 gives some exam-
ples of water pollution in different cities in the developing wcrld.
DRINKING-WATER_QUALITY CRTTERIA
The WHO Guidelines for Drinking Water Quality (WHO, 1993d) are comprehensive
in scope and intended to be used as a basis for the development of national stan-
dards. Through use of the WHO Guidelines, each country can develop its own
standards based on a risk-benefit approach. Standards that are too stringent may
have the effect of reducing or limiting available water supplies in some parts of
the world. The Guidelines are therefore designed to be realistic, adaptable, and
advisory. The overriding priorities in the Guidelines are (in priority order):
An adequate supply of water

An adequate supply of microbiologically safe water
An adequate supply of microbiologically safe water that meets the guidelines
for chemical parameters.

BOX_6.4
Water Pollution Related to Development
ACIDIFICATION
Acidification of surface and some groundwater is a slow process that is principally

caused by increased atmospheric deposition of inorganic acids. Atniospheric depo-
sition in the form of acid rain occurs worldwide through the chemical reaction of
rainwater with sulfur and nitrogen oxides, ions from coal/oil burning, and motor
vehicle traffic poiltition to air. Increased acidic deposition in some susceptible areas
has reduced the pH of lakes so that they no longer support fish or animal life. In
addition, the release of metals into lakes and streams from acidified soils presents
possible risks to human health and to fish in the lakes.
EUTROPHICATION
Eutrophication can be a natural phenomenon in lakes over long periods of time

through which organic material gradually accumulates in the lake basin during the
geological history of the lake. Added nutrients such as phosphorus and nitrogen
serve to accelerate eutrophication and make it abnormal and destructive to the lake.
Increased concentration of these nutrients has been attributed to the discharge of
wastewater into lakes, the use of fertilizers, and changes in land use that increase
runoff. Eutrophication is an established problem in many lakes and reservoirs in
highly populated indtistrialized countries and is probably the most pervasive water
quality problem on a global scale. One of the results of eutrophication is algal bloom,
which produces large increases in algae in the water of the lake, some of them pro-
ducing toxins. Eventually the lake suffering from eutrophication will get clogged up
with weeds and become a swamp or peatmarsh.
DIRECT DISCHARGE
Direct discharge of pollutants into water is usually controlled by regulations, although

it certainly still occurs. Effluent from a plant may carry waste and the byproducts of
industrial processes. Runoff from the plant site may carry chemical contaminant,
including oil, into drains and then into waterways. Holding ponds are often used to
impound the discharge and to partly decontaminate it before release. Thermal pol-
lution is a special type of discharge in which warm water heats the piercing waters
and may cause a situation similar to eutrophication. It is often a problem down-
stream from power plants.
Source: UNEP, 1993.
Many organisms present in drinking-water supplies have no real health signifi-

cance but may affect the appearance, taste, and/or odor of the water. These
organisms may also be important indicators of defective water treatment and
distribution systems.
Frequent monitoring for fecal indicator organisms is an old method of as-
sessing water quality but remains the most sensitive way of assessing the hy-
gienic quality of water. Fecal bacteria that have been chosen as indicator organ-

BOX 6.5
Some Examples of Water Pollution in Selected Cities in
Developing Countries
ALEXANDRIA, EGYPT
Most industries in Alexandria discharge untreated liquid wastes into the sea or into
Lake Maryut. In the past decade, fish production in Lake Maryut declined by some
80% because of the direct discharge of industrial and domestic effluents. The lake
has also ceased to be a prime recreational site because of its poor condition. Simi-
lar environmental degradation is taking place along the seafront due to the discharge
of untreated wastewater from poorly located sewage pipe outfalls. The paper, tex-
tile, and food industries contribute most to the organic load.
BOGOTA, COLOMBIA
The Tunjuelito, a tributary of the Bogota River, is highly polluted. Many tanneries
and plastic-processing plants pour untreated wastes into it and the dissolved oxy-
gen in the water is almost depleted. The wastes include heavy metals such as lead
and cadmium. Other rivers are not so heavily polluted with chemical wastes but re-
ceive large volumes of untreated sewage.
KARACHI, PAKISTAN
The Lyan River, which runs through Karachi, Pakistan's largest industrial city, is an
open drain, from both the chemical and the microbiological points of view, for a
mixture of raw sewage and untreated industrial effluents. Most industrial effluents
come from an industrial estate with some 300 major industries and almost three
times as many small units. Three-flfths of the units are textile mills. Most other in-
dustries in Karachi also discharge untreated effluent into the nearest water body.
SHANGHAI, CHINA
Some 3.4 M3 of industrial and domestic waste pour into the Suzhou Creek and the
Huangpu River, which flows through the heart of the city. Less than 5% of the city's
wastewater is treated, and these rivers have become the main open sewers for the
city. Most of the waste is industrial since few houses possess flush toilets. The
Huangpu has essentially been dead since 1980. The normally high water table also
means that a variety of toxins from industrial plants and local rivers find their way
into groundwater and contaminate wells, which also contribute to the water
supply.
Source: WHO, 1992a.
isms are present in high numbers in the feces of humans and warm-blooded an-
imals and are readily detectable by simple methods. They do not grow in
water itself. The major indicator organisms of fecal pollution are Escherichia coli,
thermotolerant and other coliform bacteria, the fecal streptococci and sulfite-
reducing clostridia. No water intended for human consumption should contain

TABLE 6.1
BACTERIOLOGICAL QUALITY OF DRINKING WATER (WHO GUIDELINES)
Organisms Guideline
ALL WATER INTENDED FOR DRiNKING
E. coli or therniotolerant coli orm bacteria Must not he detectable in any 100 ml sample
TREATED WATER ENTERING

DISTRIBUTION SYSTEM
E. coil or thermotolerant coliform bacteria Must not be detectable in any 100 ml sample
Total colilorm bacteria Must not be detectable in any 100 ml sample
TREATED WATER IN
DISTRIBUTION SYSTEM
E. co/i or thermotolerant colilorm bacteria Must not be delectable in any 100 ml sample
Total colilorm bacteria Must not be detectable in any 100 ml sample.
In the case of large supplies where suffi-
cient samples are examined, must not be
present in 95% of samples taken through-
- out any 12-month period
Source: WHO, I 993i1.
E. coli in any 100 ml sample. taken. Treated water should not contain total col-
iform bacteria in any 100 ml sample (Table 6.1). The indicators may or may not
be associated with the disease themselves. For example, most E. co/i do not cause
human disease, although some do. The presence of E. co/i, however, is a reliable
indicator of potential contamination by pathogens.
Monitoring Contaminants
It is not practical or necessary to monitor water for all possible chemical con-
taminants and pathogens. While it is possible to detect the presence of many
pathogens in water, the methods of isolation and enumeration are often com-
plex and time consuming. Therefore, rather than monitoring water for every pos-
sible pathogen, the more logical approach is to detect organisms normally pre-
sent in the feces of humans and other warm-blooded animals as indicators
of fecal pollution (see Table 6.1). The strategy that works is one that (a) identi-
fies episodes of contamination that might carry a significant risk and (b) closely
monitors a few specific contaminants (such as arsenic) that could cause serious
trouble.
The WHO has identified contaminants that are potentially hazardous to hu-
man health and those detected relatively frequently and in relatively high con-
centrations in drinking water. Certain indicator organisms and some 128 chem-
ical contaminants can now be assessed through comparison with guideline values.
The Guidelines for Drinking Water Quality (WHO, 1993d) apply the following prin-
ciples:
• A guideline value represents a concentration of a constituent that does not re-

sult in any significant risk to the health of the consumer over a lifetime of con-
sumption, usually assessed to be at least 70 years.

• Water that meets the criteria defined by the Guidelines for Drinking Water Qual-
ity is considered to be suitable for human consumption and for all usual do-
mestic purposes, including personal hygiene. However, water of a higher qual-
ity may be required for some special purposes, such as renal dialysis. The
Guidelines are not necessarily protective for these special applications.
• When a guideline value is exceeded, this should be a signal that something
has gone wrong in the protection system. It should trigger certain actions: (a)
to investigate the cause with a view to taking remedial action, (b) to consult
with and seek advice from the authority responsible for public health, and (c)
to take steps to ensure that the break in the system will not happen again.
• Although the guideline values describe a quality of water that is acceptable for
lifelong consumption, they should be considered a minimum for acceptability.
Guideline values should not be regarded as a target that is sufficient and that
does not require improvement. The quality of drinking water should under no
circumstances be degraded to the recommended level from a better level. In-
deed, a continuous effort should be made to maintain drinking-water quality
at the highest possible level.
• Short-term deviations above the guideline values do not necessarily mean that
the water is unsuitable for consumption. The amount by which, and the pe-
riod for which, a particular guideline value can be exceeded without affecting
public health depends upon the specific substance involved and the degree of
the deviation.
• It is recommended that when a guideline value is exceeded, the surveillance
agency (usually the authority responsible for public health) should be consulted
for advice on suitable action. The significance of an excess level may depend in
part on the total intake of the substance from all sources, taking into account
the intake of the substance from sources other than drinking water (for chem-
ical constituents), the toxicity of the substance, the likelihood and nature of any
adverse effects, the practicability of remedial measures, and similar factors.
• In developing national drinking-water standards based on these guideline val-
ues, it is necessary to take into account a variety of geographical, socioeco-
nomic, dietary, and other conditions affecting potential exposure. This may
lead to national standards that differ from the guideline values.
• In the case of radioactive substances, screening values for total alpha and to-
tal beta activity are given, based on a reference level of dose.
Microbiological Standards
Most of the disease agents that contaminate water and food are biological and
come from animal or human feces. The contaminants come in the form of path-
ogenic bacteria, viruses, protozoa or parasites. Those that can be transmitted via
the fecal-oral route by drinking water are listed in Table 6.2, together with a
summary of their health significance and main properties. These pathogens pre-
sent a serious risk of disease whenever they are present in drinking water. Many
of these pathogens are also a hazard in food (these are described further in Chap-
ter 7) and include Salmonella spp., Shigella spp., pathogenic E. co/i, Vibrio cholerae,
Yersinia enterocolitica, Campylobacter jejuni, C. co/i, the viruses listed in Table 6.2,
and the parasites Giardia, Cryptosporidiuni, Entamoeba histolytica, and Dracunculus

TABLE 6.2
WATERBORNE PATHOGENS
Persistence Resistance Relative lrnportan
Health in Water to Infective Animal
Pathogen Significance Supplies Chlorine Dose Reservoir
BACTERIA
CampylobacL'r jejuni, High Moderate Low Moderate Yes

C. cvii
Pathogenic E. cell High Moderate Low High Yes
Salmonella typhi High Moderate Low High No
Other salmonellae High Long Low High Yes
Shun/la SpP. High Short Low Moderate No
Vi brie cholerae High Short Low High Ni)
Yersinia enterocolitica High Long Low High(?) Yes
Pseudonwoas aeruqinosa Moderate May multiply Moderate High(?) No
Aeromonas Spp. Moderate May multiply Low Highi?) No
VIRUSES
Adenoviruses High ? Moderate Losv No

Enteroviruses High Long Moderate Low No
Hepatitis A High ? Moderate Low No
Enierically transmitted
non-A, non-B
hepatitis viruses,
hepatitis E High ? ? Low No
Norwalk virus High ? ? Moderate No(?
Rotavirus High ? ? Moderate No)?)
Small round viruses Moderate ? ? Low)?) No
PROTOZOA
Eotamoeba histo/ytica High Moderate High Low No

Glen/ia intestinalis High Moderate High Low Yes
Cryptosporidium parvroii High Long High Losv Yes
HELMINTHS
Dracuncu/us niedmensis High Moderate Moderate Low Yes

Source: WHO, 1993d
medinensis. Most of these pathogens are distributed through water worldwide,

however, outbreaks of cholera and infection by the guinea worm D. medinensis
are regional. Other pathogens are accorded moderate priority in Table 6.2 or not
listed because they are of lower pathogenicity. These parasites often cause dis-
ease opportunistically in persons with low or impaired immune systems, for ex-
ample, in elderly people or people with AIDS.
Acceptable Daily Intake and Guideline Values for Chemicals

How are the risks of different chemicals determined? There are two principal
sources of information on health effects resulting from exposure to chemicals
that can be used to develop guidelines. The first is to he found in studies on hu-
man populations, studies that are often limited by a lack of quantitative infor-

Ination on the concentrations to which people are exposed. The second is found
in toxicity studies on laboratory animals and is the source that is used most of-
ten (see Chapter 3). In the WHO's Guidelines for Drinking Water Quality (WHO,
1993d), the following formulas are used to determine tolerable intake of various
chemicals, and these should be consulted for an in-depth discussion of the for-
mula derivations. The formulas presented below refer specifically to drinking wa-
ter, but they use terminology similar to that used for other topics in risk assess-
ment (Chapter 3).
For most kinds of toxic chemicals studied, there is a dose below which no ad-
verse effects have been observed. For such chemicals an acceptable daily intake
(ADI) can be derived as follows:
ADI = NOAEL or LOAEL

UF
where: NOAEL = no-observed-adverse-effect level, LOAEL = lowest-observed-

adverse-effect level, and UF = uncertainty factor.
The guideline value (GV) is then derived from the ADI as follows:
ADI )< bw>< P

GV=
where bw = body weight (60 kg for adults, 10 kg for children, 5 kg for infants),
P = fraction of the ADI allocated to drinking water, and C = daily drinking-
water consumption (2 liters for adults, I liter for children 0.75 liters for infants).
• The ADI is an estimate of the amount of a substance in food or drinking wa-

ter, expressed on a body weight basis, that can be ingested daily over a life-
time without appreciable health risk.
• The proposed ADIs are regarded as tolerable throughout life; they are not set
with such precision that they cannot be exceeded for short periods of time.
Short-term exposure to levels exceeding the ADI is not a cause for concern,
provided the individual's intake averaged over longer periods of time does not
exceed the ADI.
• It is impossible to make generalizations concerning the length of time during
which intakes in excess of the ADI would be toxicologically detrimental. The
induction of detrimental effects will depend upon factors that vary from con-
taminant to contaminant. The biological half-life of the contaminant, the na-
ture of the toxicity, and the amount by which the exposure exceeds the AD!
are all crucial.
• The large uncertainty factors generally involved in establishing an AD! also
serve to provide assurance that exposure exceeding the ADI for short time pe-
riods is unlikely to result in any deleterious effects upon health. However, con-
sideration should he given to the potentially acute toxic effects that are not
normally considered in the assessment of an ADL
• The GV is generally rounded to one significant figure to reflect the uncertainty
in animal toxicity data and exposure assumptions made. More than one sig-

nificant figure is used for GVs only when extensive information on toxicity
and exposure provides greater certainty.
As noted earlier, carcinogens, which are generally genotoxic chemicals, have

no detectable threshold for consumption and consequently may be harmful at
any level of exposure. The development of an ADI for these chemicals is there-
fore inappropriate, as was discussed in Chapter 2. The initiating event in the
process of chemical carcinogenesis is the induction of a mutation in the genetic
material (DNA) of somatic cells. There are carcinogens, however, that are capa-
ble of producing tumors without genoloxic activity, but through an indirect mech-
anism. It is generally believed that a threshold dose exists for these nongenotoxic
carcinogens, but in most cases this threshold has not been determined.
For carcinogens for which there is convincing evidence to suggest a nongeno-
tcxic mechanism, guideline values are calculated using an ADI approach. In the
case of genotoxic carcinogens, guideline values were determined by means of a
mathematical model, and the guideline values are presented as the concentra-
tion in drinking water associated with an estimated excess lifetime cancer risk of
io - ( one additional cancer case per 100,000 of the population ingesting drink-
ing water containing the substance at the guideline value for 70 years).
DfflNKING-WATERSUPPLYANDMONITORIN___
The Source
Proper selection and protection of water sources are critical for the provision
of safe water. It is always better to protect water from contamination than to
treat it after it has been contaminated. Before determining that a source of wa-
ter will be used as a drinking-water supply, it is important to ensure that the
quality of the water is satisfactory or treatable and that the quantity available
is sufficient to meet continuing water demands. Seasonal variations and p0-
tential growth of the community must be taken into account to ensure that
there are no shortages. Sources of groundwater such as springs and wells should
be sited and constructed so they are protected from surface drainage and flood-
ing. Areas of groundwater abstraction should be fenced in and kept clear of
garbage.
The protection of surface water is more problematic. Surface water such as
streams, rivers, and lakes are more vulnerable to pollution. The water source should
be protected from human activities. If possible, the source should be isolated and
there should be control over polluting activities in the area, such as dumping of
hazardous wastes, mining, and agricultural use of fertilizers and pesticides. Recre-
ational activities should be limited so that they are not likely to introduce conta-
mination. While it may be possible to protect a reservoir from major human ac-
tivity, this may be more difficult to enforce in the case of a river. Often it is necessary
to accept existing uses of a lake or river and design treatment accordingly.
In areas where drinking water is collected from roofs it is important to avoid
contamination from paint on the roof or in the storage tanks. In addition, an in-
crease in air pollution may add to poor-quality roof water.

BOX cf;
GEMS/Water
The United Nations Environment Program's Earthwatch office and the Global En-
vironment Monitoring System (GEMS), in association with the WHO, UNESCO, and
the World Meteorological Organization, have developed a global water quality mon-
itoring network, called GEMS/Water. Initiated in 1977, the network includes 344
monitoring stations-240 river stations, 43 lake stations, and 61 groundwater sta-
tions. Rivers such as the Rhine, the Nile, and the Ganges, and lakes, from Lake Tal
in China to the North American Great Lakes, are routinely sampled and analyzed.
Groundwater, crucial for drinking-water supplies, is sampled in Africa and the Mid-
dle East, particularly in areas where no perennial rivers flow. More than 50 water
variables are measured, providing information on the suitability of water for hu-
man consumption, and for agricultural, commercial, and industrial uses. All data
are stored and processed at the GEMS/Water global data bank at the National Wa-
ter Research Institute in Canada, and summaries of the data are published every 3
years. In 1990. the GEMS/Water Program broadened its scope to include not only
monitoring but data interpretation, assessment of critical water quality issues, and
management option analysis.
Whereas guideline values have been set for drinking water itself, no firm re-
quirements can be formulated for the source of such water (WHO/UNEP, 1989).
Waler quality monitoring, however, is in place in several countries through the
GEMS project (Box 6.6).
Drinking water can also be produced froin seawater through desalination. This
is common in countries with little rainfall and large oil supplies, e.g., Bahrain
and Curaçao. The process of removal of salt from seawater involves boiling, dis-
tillation, or reverse osmosis, all technologies with high energy requirements.
Treatment of Drinking Wafer

Proper treatment of drinking water protects the consumer from health risks as-
sociated with biological or chemical hazards in the water. The quality of the orig-
inal source of water determines the extent of treatment required. The number
of people served by a particular drinking-water supply also influences the treat-
ment process. If the water comes from a source serving only one or a few house-
holds, the treatment may take place at the site of consumption rather than at
the source or in the distribution system, which is the rule for large population
supplies. Water purification filters and disinfecting tablets can be used at the
household end. It is even better to protect the household source, such as a well,
so that the water can he used directly with minimal treatment or handling.
The most common treatment methods include (a) pretreatment in reservoirs;
(b) coagulation, flocculation, and sedimentation; (c) filtration; and (d) disinfec-
tion (see Box 6.7 and Fig. 6.5). Details of these methods are given in the WHO's
228 z5asic Environmental Health

Water Treatment and Chlorination By-Products
A typical water treatment facility, as may be found in large cities in Canada, is shown
in Figure 6.5. After water is drawn from a source, large debris is removed via a
screen. A disinfectant is then added to reduce bacteria. The process of coagulation,
flocculation, sedimentation, and filtration constitutes the treatment process. Through
coagulation and flocculation particulate impurities are removed; adding a coagulant
causes the particles to clump, whereas flocculation is a slow stirring process during
which the particles gather together to form larger particles. Sedimentation is used
to remove suspended solids that have been preconditioned by the coagulation-
flocculation process, following which a filter completes the process of removing sus-
pended solids. Sometimes a disinfectant is added before the distribution of treated
water. -
Trihalomethanes (THMs) result from the reaction of chlorine with organic pre-
cursors during the water treatment process. Several ecological studies have exam-
med the relationship between THM5 and cancer. These studies have generally sug-
gested that there is an association between THMs and cancer of the bladder and
colon. Some of the studies have also reported that incidence of cancers of the rec-
tum, stomach, breast, lung, pancreas, and kidney and non-Hodgkin's disease may
increase in association with THM5. Some case—control studies have also suggested
significant associations for cancers of the bladder, colon and rectum. The sum of the
available evidence points to a small increased risk of some cancers associated with
consuming water with high levels of THMs.
Characteristics of the treatment process affect the amount of chlorine compounds
and organic precursors in treated water. The stage at which disinfection is performed
is important in determining the THM level, since other treatment procedures will
affect the level of organic precursors available to react with chlorine. For example,
when chlorine compounds are added before any treatmeni, the largest levels of
THM5 result. This effect is tempered by using activated carbon later in the process,
as it has the potential to remove volatile organic compounds. The amount of chlo-
rine by-products in treated water can also be reduced with dechlorination.
It is important to recognize that disinfection is an important component of wa-
ter treatment. While measures should be followed to reduce cancer risk to a mini-
mum, the health risks associated with failing to chiorodisinfect water lar exceed the
risks of chlorination, according to current knowledge.
Source: Marrett and King, 1995.
Guidelines document (WHO, 1993d). One of the basic elements of the treatment
methods is sedimentation of larger particles in reservoirs, where special screens
can further reduce the amount of organic matter in the water. Predisinfection
with chlorine compounds can also be used in this process if the water is known
to be polluted by sewage. In the coagulation step, aluminium or iron compounds
are added, which react with impurities in the water to cause flocculation (cre-
ation of slimy particles, called floes, in the water). These flocs will attach to bac-
teria and other remaining organic material in the water, and the flocs can be sep-

Screen & Flash Coagulation Sedimentation Filter Storage High-lift
low-lift Mixers Flocculator pumps
Disinfectant Algicide Disinfectant

Taste & odour Disinfectant
Coagulants Taste & odour
Coagulant aids Coagulant aids Disinfectant
Ph adjustment Dechlorination
Algicide Disinfectant Disinfectant
Taste & odour Taste & odour Taste & odour
Coagulants Ph adjustment
Coagulant aids Corrosion control
Softening Acidifier
Fluorides
Chloramine
Dechlorinating
Figure 6.5 Diagram of a water treatment process. From Marrett and King, 1995, with per-
mission.
arated from the water by sedimentation or flotation. To ensure that all floes and
most bacteria are removed from the water, the next step includes filtration in
sand, The longer distance of sand the water filters through, the more efficient
the filtration. Normally, bacterial counts can be reduced by a factor of about 1000
by a suitable sand filter.
Even after thorough sand liltration, some bacteria and viruses may remain,
so a final disinfection is extremely important. The most commonly used meth-
ods involve the addition of chlorine or hypochlorite to the water. Disinfection
can also be achieved with chloramines, chlorine dioxide, ozone, and ultraviolet
(UV) radiation. The latter method has been applied in small-scale solar-powered
disinfection units, and this may he the method of choice for remote areas with
much sunlight. The chlorination process makes it possible to maintain a certain
level of free residual chlorine in the water during its transport through the dis-
tribution system. This reduces the buildup of bacterial and algae growth inside
the pipes, and it maintains some protection from contamination of the water dur-
irig transport. In large population supply systems, the water source is often prone
to contamination and the storage and distribution systems can be contaminated.
Chlorine is preferred because it continues to act downstream. In Box 6.7 chlori-
nation of drinking water is discussed further.
In some countries, fluoridation of drinking water is as an approach to increase
the daily intake of fluoride to levels that prevent caries in teeth. This practice has
been controversial because excessive intake of fluoride can have detrimental health
effects and can discolcr teeth (see Chemical and Radioactive Constituents of Water,
above). Individual intake is diflicult to control. Fluoride in toothpaste provides sig-
nificant exposure for people who use such toothpaste. The fluoridation of water sup-
plies is nonetheless promoted as an essential intervention for preventive oral health.
Distribution and Storage
Where high-quality piped water is readily available in the home, monitoring of
water quality can be done directly at the time of use. According to the WHO's

Guidelines, these conditions are "globally the exception rather than the rule"
(WHO, 1993d). Many people worldwide collect water away from the point of
use or store water in unsanitary conditions in their homes. In cases where an
adequate supply is present, contamination may occur in household storage tanks
if they are not property installed and maintained. Contamination can also occur
during distribution of water from the source to the household, through the use
of dirty containers and/or coverings. Contamination of water in the home may
be the most important source of microbiological contamination throughout the
world. Educational initiatives on the subject of water handling and the promo-
tion of storage tank maintenance can reduce this risk to human health.
Place of Use
As discussed in Chapter 4, Factors Affecting the Perception and Acceptance of
Risk, many organisms present in water have no real health significance but may
be important indicators of other problems with either the water supply or the
water distribution system. Consumers cannot usually assess the safety of their
water systems themselves but their attitude toward their water supply and wa-
ter suppliers will certainly be affected by what they can perceive themselves. The
provision of water that is not only safe but physically acceptable is important to
a community (see Other Aspects of Water Quality, above).
Heat kills bacteria and protozoa and destroys viruses. Boiling water is a very
effective means of treating water for biological contamination but it is ineffective
for controlling chemical contamination. It is also very expensive, especially where
fuel is in scarce supply. Water can also be filtered at the place of use. For small
volumes, disinfection chemicals can be used to treat highly contaminated water.
Small-scale systems based on solar UV radiation as a disinfectant have been de-
veloped.
cANTTATTON
Throughout this chapter numerous references have been made to sewage, cx-
creta, or fecal contamination. The prevalence of waterborne diseases resulting
from this type of contamination raises the obvious question of what can be done
to improve sanitation. In the 1970s, international agencies began to look at al-
ternative low-cost sanitation technologies for rural and low to medium-density
urban settlements. There are now over 20 different excreta disposal systems that
offer varying degrees of convenience and protection. One such system, the ven-
tilated improved pit (VIP) latrine, is outlined in Box 6.8 and Figure 6.6. Larger-
scale sewage systems for urban areas are described in the section Wastewater
Treatment and Reuse, below. Concerted efforts during the 1980s brought im-
proved water and sanitation services to many of the world's poorest people. Al-
though the target of the International Drinking Water Supply and Sanitation
Decade (IDWSSD), discussed in the last section of this chapter, was to provide
safe drinking water and sanitation to underserved urban and rural communities
by 1990, the progress of the decade was not enough.
Most urban centers in Africa and Asia have no sewage system at all, includ-
ing many cities with a million or more inhabitants (WHO, 1992a). In 1994 at

BOX 6.8
Ventilated Improved Pit Latrine
A ventilated improved pit latrine (VIP) is an improved version of the traditional pit
latrine. The main difference between a VIP and a pit latrine is that a VIP has a vent
pipe with a fly screen at the top. The vent pipe and fly screen together have two
effects: increased ventilation and fly control. The vent pipe creates a flow of fresh
air through the cubicle and pit. As wind blows over the top of the vent pipe, it sucks
air up the pipe and out of the pit. Fresh air is then drawn from outside, through
the cubicle, and down into the pit. The toilet itself is therefore odorless (see Fig.
66a). Flies approaching the latrine are attracted to the odors coming from the pipe,
but cannot pass the screen to enter the pit. Flies escaping from the pit are attracted
to the light coming down the pipe, but are trapped by the screen and cannot leave.
Thus far fewer flies are attracted to and able to breed in the toilet (see Fig. 6.6b).
FIGURE 6.6 Ventilated improved pit (VIP) latrine. In addition to the vent pipe and fly-
screen, the following are other important features of a VIP toilet: (1) Apart from the holes
for the vent pipe and the toilet seat, the pit should be completely sealed by the slab to
prevent odors (B) and flies (A) from escaping. (2) In soft ground the pit should be lined,
to prevent the toilet from collapsing. If the ground is solid, it may only be necessary to
line the top part of the pit. (3) The superstructure interior must be shaded (i.e., light niust
not be allowed to enter it directly), as this attracts flies from the pit. (4) The toilet must
be well maintained and kept clean for it to work properly. Contributed by D. Carter, The
MVULA Trust.

TABLE 6.3
URBAN WATER AND SANITATION COVERAGE BY REGION, 1994
Asia and
Africa Pacific Middle East Latin America
Service (%) (%) (%) (%)
WATER
Population covered 68.9 80.9 71.8 91.4

Served by house connection 65 48.4 89.7 92
Served by public standpost 26 24 9.3 3.3
Served by other 9 27.6 0 4.7
SANITATION
Population covered 53.2 69.8 60.5 79.8

Served by house connection to
sewer/septic system 53.0 42.7 100.0 91.2
Pour-flush latrine 3.0 43.1 0 2.1
Ventilated improved pit latrine 13.6 2.7 0 0.9
Simple pit latrine 22.4 8.5 0 5.4
Other 2.6 3.0 0 0.4
Reproduced Irom WRt/ UNEP/UNDP! World Bank, 1996, with permission.
least 220 million people still lacked an easily accessible source of potable water
(see Table 6.3) (WRI, 1996). Figures for water supply and sanitation often un-
derstate the problem because they do not take into account the quantity of wa-
ter needed by a household for proper hygienic practices. Moreover, figures given
for clean water sources or adequate sanitation facilities in a comtnunity may also
conceal some problems. If people have to wait in long lines for their water, they
often reduce their water consumption below what is needed for good health
(WHO, 1992a). People who have to walk long distances to use a latrine may end
up defecating where it is most convenient to save effort. Improving sanitation
will only work if other factors such as personal hygiene and adequate water sup-
ply are addressed simultaneously. Improving access to water and sanitation fa-
cilities alone can reduce the incidence of diarrheal disease by at least 20% (WRI,
1996).
As noted in Our Planet Our Health (WHO, 1992a), capital costs alone are not
a sufficient basis for determining the cost of a system because some systems
are more expensive than others to operate and maintain. The total discounted
capital, operation, and maintenance costs for each household must be calcu-
lated to determine the charge that must be levied for the service and establish
whether households can afford to pay for the service. If the monthly cost of
providing sanitation exceeds 5% of the family income, it may be considered
unaffordable. Most low-cost sanitation alternatives come within this range,
even for the poorest of communities. Table 6.4 outlines typical sanitation fa-
cilities and their costs. Costs are a crucial factor in the choice of sanitation sys-
tems, but a number of other determinants such as settlement and population
density, ground conditions, and social and cultural practices will also play a
role.

TABLE 64
CAPITAL COSTS OF SANITATION SYSTEMS (1990 PRICES)
Type of System Cost (U.S. $) per Household (1990)
Twin-pit pour-flush latrine 75—I 50
Ventilated improved pit latrine 68-175
Shallow sewerage 100-325
small-bore sewerage 150-500
Lonvenuonal septic tank 200-600
onventional sewerage 600-1200
Reproduced from WHO, 1 9Q2a, with permission.
CONTROL OF WATER POLLUTION
Domestic sewage, stormwaler runoff, and industrial wastes have all been men-
tioned in this chapter as significant contributors to water quality degradation. A
few decades ago, it was considered economically acceptable to turn over some
water courses entirely to waste disposal, with other water bodies being reserved
for drinking water. However, this is no longer acceptable practice. The increase
of population density in urban areas, the concern for environmental protection,
the g7reater understanding of the links between the environment and health, and
a better assessment of the economic damage of water pollution have all served
to motivate an improvement in pollution control practices (Hespanol and Helmer.
1993).
As highlighted in Bcx 6.5, many of the rivers that flow through the devel-
oping world's major cities are little more than open sewers. Untreated industrial
and municipal wastes add pollution loads far beyond the rivers' self-purifying ca-
pacities. While these rivers and other surface water bodies are highly visible signs
of pollution, less visible but equally dangerous is the contamination taking place
in groundwater. The attraction of groundwater as a supply source has led to over-
expkntation. This in turn has led to a number of quality problems. As the nat-
ural water table falls, saline water is drawn in to replace the fresh water. Seep-
age through the soil can contaminate groundwater with pathogens from sewage,
as well as a wide variety of potentially toxic compounds dumped by industry.
Improvements in sanitation, wastewater treatment and reuse, and in the regu-
lation of industrial pollution need to he priority areas for controlling the pollu-
tion of both surface and groundwater sources.
Industrial Fe/lu tion

Industrial wastes degrade water quality when proper disposal methods are not
in place. The water may become so polluted that it is not fit for other uses. Many
factories in developing countries have been built without effective waste treat-
ment and disposal systems, since costs would increase production costs and ac-
cordingly reduce a product's competitiveness on the international market. In-
dustrial wastes, especially those containing heavy metals and organic chemicals,
may leave a particularly severe impact due to their persistence, their harmful ef-
fects at low concentrations, and their ability to enter the food chain (Hespanol
and Helmer, 1993).

Agenda 21 recognizes that "gross chemical contamination, with grave damage
to human health . . . and the environment, has in recent times been continuing
within some of the world's most important industrial areas. Restoration will re-
quire major investment and development of new techniques" (UN, 1993). In
every country there must be an appropriate legislative framework developed to
support a public administration that can issue and enforce regulations and re-
sponsibilities, and develop control policies.
VVastewater Treatment and Reuse

Treatment Wastewater treatment accounts for the largest part of the costs asso-
ciated with urban sanitation. The level of wastewater treatment established
should be consistent with the characteristics of the receiving waters to which the
effluents will be discharged after treatment or according to reuse practices. When
choosing a treatment system decision makers have to take into account the avail-
ability of forms, equipment, and expertise. The system must also be adapted to
local climatic conditions, particularly where there is flooding, to support water
treatment locally.
There are three levels of wastewater treatment: primary, secondary, and ter-
tiary. In primary treatment, sewage is held in settling tanks and solid materials are
allowed to settle out of the water. Bacterial action digests organic materials and
the sludge that remains is dried and disposed of. Excess sludge from biological
treatment plants can be composted to produce a stable biomass that is free of
pathogens and can be applied to agricultural land as a soil conditioner. In sec-
ondary treatment, further degradation of wastewater organics is accomplished by
bacteria in an oxygen-rich environment, created by blowing or shipping air into
the wastewater. Tertiary treatment involves chemical separation of phosphates and
nitrates and in some cases further action by bacteria in ponds or through filtra-
tion.
The most common tertiary treatment systems used in both developing and
industrialized countries are based on processes such as the following:
• stabilization ponds
• activated sludge
• trickling filters and towers
• aerated lagoons
• upflow anaerobic sludge blanket reactors (UASBR).
The choice of treatment depends on such factors as land availability, power re-
quirements, and availability of skilled operators. The UASBR5 have low power
and land requirements. Stabilization ponds require large amounts of land but arc
simple and inexpensive to operate. Activated sludge plants require considerable
amounts of power as well as skilled operation.
Wastewater is a valuable resource that plays an important role in the man-
agement of water resources (WHO, 1980b). Worldwide, water withdrawal for ir-
rigation accounts for nearly 70% of all use. By using wastewater for irrigation,
particularly in and or semi-arid parts of the world, high-quality water currently
being used for agriculture could instead be made available for drinking. Reuse of

wastewater for irrigation of crops may help to increase food production while
improving health and social conditions. The use of vvastcwater for irrigation or
aquaculture can prevent problems associated with the discharge of untreated or
partially treated wastewater into rivers and lakes. Additionally, by reducing the
dependence on groundwater for irrigation, the use of wastewater helps to di-
minish the problems of saltwater intrusion into aquifers. Wastewater can be used
particularly effectively in forestry and thus he of aid to arid developing areas or
countries suffering from deforestation.
If wastewater used in irrigation is not carefully controlled, health problems
may result. The following integrated safeguard measures can be used to protect
the health of people who may be at risk from wastewater use systems:
• Wastewater treatment, to ensure that the wastewater applied to crops has low
levels of pathogenic organisms
Wastewater application techniques, such as drip irrigation, that avoid wastewater
coming into contact with the edible parts of crops
o Crop selection, to limit the use of wastewater for irrigating crops that are not
consumed directly (industrial and fodder crops) or that grow well above the
ground (tomatoes and chili), or crops not eaten raw (potatoes)
Human exposure control, by advising farm workers, crop handlers, and consumers
of potential hazards through programs of health education, by immunizations,
by providing treatment and adequate medical facilities to treat diarrheal dis-
eases
RECREATJOt'IAI. WATER QUALITY GUTDFI TNFS

Recreational uses of water include swimming, boating and diving. Although wa-
ter quality for these uses does riot have to be as stringent as for drinking water,
there must he some controls to prevent contamination and waterhorne diseases
from recreational water uses. Recreational water quality is becoming an increas-
irigly important issue because of the economic importance of tourism around the
globe. Recreational water quality guidelines have mostly been the concern of de-
veloped countries. Although acceptable levels of microorganisms and contami-
nants will vary from country to country, the method of assessing the water qual-
ity is fairly standardized among developed countries. The recommended levels
given here are from the Guidelines for Canadian Recreational Water Quality (Health
Canada, 1992). Several aspects of recreational water are examined: presence of
pathogens and physical and chemical characteristics.
Indicator organisms are often used for determining the presence of pathogens.
These organisms are not toxic in and of themselves but reflect the levels of path-
ogenic organisms that are probably present in the water. Several orgahisms lend
themselves to this task, depending on the resources available to the tester and the
nature of the body of water. In freshwater, fecal coliforms are often measured,
but there is some debate about the strength of the correlation between their 1ev-
els and the risk of disease. It is recommended that levels not exceed 200 fecal Cu-
liform/100 ml over a 5-day period. Fccal coliforms are not useful in salt water.
Fecal streptococci may be a better choice for both fresh- and saltwater, but at pre-

sent the methods available for determining their levels are more expensive. Other
pathogenic organisms should be measured when there is epidemiological evidence
that pathogens are present in a particular body or area of water.
Recreational water quality is also dependent on physical and chemical char-
acteristics. Although water temperature is an important quality aesthetically, and
for comfort, humans can tolerate a wide range of temperatures. The optimum for
swimming is in the range 18 0-25°C. Prolonged submersion into colder or hotter
water may lead to some of the physical effects discussed in Chapter 2. Acidic and
alkaline pH levels are also a consideration but are not extreme enough to affect
humans adversely. The recommended range is between 6.5 and 8.5. Turbidity is
important in determining water quality because the presence of pathogens is sig-
nificantly higher in sediment than in surface water. The maximum suggested level
is 50 nephelometric turbidity units (NTU). Color and clarity can also be important
qualities, but they vary so dramatically among different areas of water, depend-
ing on the contaminant, that guidelines are difficult to establish. Oil and grease
should not be visible, either on the surface or shore, and no odor should be de-
tectable. Both organic and inorganic contaminants vary dramatically and there-
fore should be measured and the health risk assessed on an individual basis. Al-
though recreational water does not require the same level of protection as drinking
water, proximity to sources of pollutants should also be considered.
ENSURING A SAFF AND SUFFICIENT WATER SUPPLY
The Water Decade, 1981-1990

Drinking-water supply has been a top priority of the United Nations. The United
Nations Conference on Human Settlements held in Vancouver in 1976 and the
Mar dcl Plata Action Plan (Mar. del Plata, Argentina March, 1977) set the stage
for the launching of the International Drinking Water Supply and Sanitation Decade
100
F_ • 1970
O 1980
0 1990
80
a)
>
a)
0)
0
60
a-
0
a-
540
20
Figure 6.7 Water supply and

sanitation access in developing
0 '—s- $_-i -L
Countries. From UNEP, 1992a, urban rural urban rural
with permission. water water Sanitation sanitation
WATER AND SANifATION 237

BOX 6.9
The Mvula Trust: A Community-Centered Approach to
Improving Water and Sanitation Services
South Africa had a long history of racial discrimination and inequality. The coun-
try had its first democratic elections in 1994. South Africa was left with a huge
legacy of inequalities, among them unequal environmental conditions. The chal-
lenge of providing the entire country's population with a basic and sustainable level
of water supply and sanitation service is enormous. The Mvula Trust is a non-
governmental organization (NGO) dedicated to improving water supply and sanita-
lion services to disadvantaged, poor, and marginalized rural communities. It pro-
vides funds mainly to villages that are remote and have low incomes. Local
government structures in South Africa are very new, with little capacity to main-
tain service infrastructure. Overcoming these difficulties to achieve sustainability re-
quires innovative approaches to all aspects of project design and implementation.
The technologies installed must be easy for the community to maintain, and they
must be affordable. However, the most important element in sustainability is that
the community must have a sense of ownership and responsibility for the scheme.
For this reason a community-centred approach to project design and implementa-
tion is essential. The Mvula Trust has developed an approach based on the follow-
ing principles.
DEMAND DRIVEN
The Trust only responds to requests for assistance from communities. It does not
search for projects, nor does it respond to proposals from consultants unless they
are in support of a community application. Without effective, gentnne demand for
the service and for the level at which it is to be installed, there is unlikely to he a
commitment to the smooth implementation of the project and, more importantly,
to the maintenance of the scheme.
CONCEPT OF OWNERSHIP
The Trust approach stresses community ownership of the process and the product
of the project. The Trtist only enters into a contract with the association represent-
ing the community, which is then expected to open a bank account, procure ma-
terials, employ labor, pay consultants, and set up a tariff collection systeni.
COMMUNITY IS THE CLIENT
In order for the community to take an active interest in the ongoing maintenance
of the scheme, it is essential that the facilities effectively serve their needs. Key de-
cisions regarding the design of the system and the implementation of the project
must therefore be niade by the community, within a set of clear guidelines, such as
the policies of the funding agency. Without this, there is a risk that an inappropri-
ate system will be installed.
COST SHARING
The principle of paying for services is basic to the South Afrkan government's re-
construction and development program, which the Trust supports. The Trust ex-
pects the community to start contributing cash to a special fund as soon as the pro-
238 Bctsic Environmental Health

'itt[,iueJi
ject starts. The process through which the association must go to raise the contri-
butions to this fund sets a precedent for the collection of operation and rnainte-
nance fees.
CAPACITY BUILDING
A key element in promoting sustainability is to develop the skills needed to take re-
sponsibility for the scheme. All Trust-funded projects have a large training compo-
nent, and the community is given the opportunity to put their training into prac-
tice during the course of the project. This develops a strong sense of self-reliance
needed to run the project after completion.
The government Department of Water Affairs and the Trust have entered into
an innovative agreement. The Trust receives most of its funding from the Depart-
ment but it is allowed to be separately accountable for public funds. This enables it
to retain a flexible NGO structure that can implement rapid, demand-driven
processes to support community empowerment.
Contributed by I. Wilson, Mvula Trust.
(IDWSSD, 1981-1990) by the General Assembly of the United Nations in 1980.

The main objective of the Decade was to substantially improve the standards and
levels of services in drinking-water supply and sanitation by the year 1990.
According to Saving Our Planet (UNEP, 1992a), the percentage of the popula-
tion in urban areas of developing countries with access to safe drinking water in-
creased from 67% in 1970 to 82% in 1990, but access to sanitation services hardly
improved at all. In rural areas improvements were more dramatic, with the per-
centage of people having clean water rising from 14% to 63% and those with
access to sanitation services rising from 11% to 49% (see Fig. 6.7). Even so, at
the end of the Decade there were still one billion people without a safe water
supply and almost 1.8 billion without adequate sanitation. The rate of progress
achieved during the Decade would be insufficient to reach the ultimate objective
of sanitation for all by the end of the century. The stow progress of achieving
the goals of the IDWSSD has been attributed to several factors, including popu-
lation growth, rural—urban migration, the unfavorable world econommc situation,
and the debt burden of developing countries. The debt burden has been a ma-
jor obstacle to investment in infrastructure (UNEP, 1992a).
As discussed in Our Planet, Our Health (WHO, I 992a), there are a number of
lessons to he learned from the Decade, some of which are outlined below:
• The ability of communities to run and maintain their own sanitation and wa-
ter systems needs to be strengthened.
• There needs to he greater emphasis on the connections between improvements
in water and sanitation and improvements in hygiene and primary health care.
• It is important to involve local populations in decisions regarding design, costs,
and management of projects.
• Disease risk and socioeconomic conditions must be considered in the design
and delivery of water and sanitation services.

Many development programs have tried to incorporate these lessons into their
various projects. The Rural Water Supply and Sanitation Project in Ghana's Volta
Region is one example of this approach; many examples are provided in the var-
ous international agency publications cited in this chapter. The efforts of the
Mvula Trust in South Africa are described in Box 6.9.
Water Resources Management

Consumers, suppliers, industry, and governments all have a role to play in en-
suring a safe and sustainable water supply. Leakage is one of the main reasons
for the shortfall in capacity of many cities' water supplies. This is particularly true
of urban centers in developing countries where typically 30% of the water is
treated and pumped into the water supply but as much as 60% is list on its way.
The leakage rate in the United States and Europe is typically around 12%. Proper
maintenance of the distribution system is an important way to cut back on wa-
ter waste. Pressure provides the force that moves water through a pipe. When
pressure cannot be kept at an adequate level, water cannot be delivered where
it is needed and contaminated water outside the pipe can seep into the clean wa-
ter inside the pipe through leaks. Maintaining adequate pressure requires care-
ful maintenance of pumps and energy to run them. As indicated earlier, gov-
ernments have an important role to play in the management of water resources,
particularly where it relates to pollution control, through appropriate legislative
frameworks.
The use of economic devices is also a powerful means of promoting efficient
environmental protection and the rational use of water resources by all users,
including households, municipalities, industry, and farmers. Public awareness of
pricing structures that reflect the real cost of water supply encourages more ef-
fident use of water. Of all natural resources, water is most likely to be consumed
at a lower price than the cost to deliver it, as the costs of water utilities are rarely
fully recouped from consumers. The most widely known basic principle in this
category, the polluter-pai's principle, is Principle 16 in Agenda 21 and reads as fol-
loves:
National authorities should endeavour to promote the internalization of environ-
mental costs and the use of economic instruments, taking into account the approach
that the polluter should, in principle, bear the cost of pollution, with due regard to
the public interest and without distorting international trade and investment.
Source: UN, 1993.
Economic instruments used to put this principle into practice include effluent
charges, subsidies to pollution control works, financial enforcement incentives,
tax rebates, and budgetary and fiscal mechanisms. Financial incentives that as-
sist polluters to protect the environment, although not universally accepted, are
in widespread use. Grants, low-interest loans, and tax credits are incentives given
to encourage remedial measures. Financial assistance can he a powerful instru-
mert in environmental protection programs, particularly in developing countries
(Hespanol and Helmer, 1993).
Significant progress cannot be made in ensuring water supply and proction
without a strong commitment at the governmental level, as large expenditures

for infrastructure are required. Some actions can be taken at an individual level,
however. Water wastage is common in many homes in developed countries. Only
5 0% of household water consumption in North America is for drinking and cook-
ing; the rest is consumed through toilet flushing (40 0%), showering/bathing
(30%), laundry/dishwashing (20%), and other uses (5 1/0). Most of this water has
been treated to a level that is sale to drink, which requires an enormous amount
of additional resources. When a lit of treated water is used for purposes that do
not require treatment, such as flushing toilets, water and treatment costs are
raised. Since it is not generally practical or safe (there is a potential hazard if
treated and untreated water lines get crossed) to have a second distribution sys-
tem for untreated water, the only solution is to minimize the waste.
Study uesti2Is
What factors need to be considered to develop an effective strategy to im-
prove sanitation in a rural community of a developing country? Of an urban
community?
A number of initiatives and suggestions for better management of water
resources have been discussed in this chapter. Try to develop other initiatives
that could be used to promote water conservation. These could be economic, so-
cial, legal, or physical in nature. Think about how these may be implemented.
Make a list of ten tips to reduce water consumption in a community af-
fected by water shortage.

7
FOOD AND AGRICULTURE
LEARNING OBJECTIVES

• indicate in what ways food may influence human health
• describe the health impacts of nutritional deficiencies
• indicate crucial environmental conditions for food production
• explain the relationship between the environment and food security
• define and illustrate the difference between food poisoning and foodborne
infections
• summarize different types of food contaminants, the sources of these con-
taminants, and their potential health impacts
• indicate various possible routes of transmission of biological food contam-
inants
• identify the hazards and risks at the various stages between food produc-
i:ion and consumption
• describe the impact of the Hazard Analysis and Critical Control Point
(HACCP) system on food safety
• illustrate the importance of recognizing differences between perceived risks
and objective risk estimations with regard to food safety
• summarize occupational health hazards related to agriculture and indi-
cate risk reduction strategies
CF[APTER CONTFTS
Health and Nutrition Nutritional Value

Physiological Requirements Food Safety
Food and Culture Regulatory Authorities and
Effects of Nutritional Deficiencies Standard Setting
on Health Food Quality Assurance
Fcodborne Diseases and Food Poisoning Production of Raw Materials
Biological Contaminants Food Processing
Chemical Contaminants Food Preservation and Storage
Radioactive Contaminants Food Preparation in the Home
Food Quality Criteria Food Preparation in the Food
Overview Services Industry
242
Global Food Production Capacity and Production and Use of Pesticides
Food Security Populations at Risk for Exposure
World Food Situation to Pesticides
Crucial Conditions for Food Toxic Effects of Pesticides
Production Integrated Pest Management
Environment and Food Security Fertilizers
Global Trends Modern Intensive Farming
Environmental and Occupational Health Methods
Hazards in Agriculture Prevention and Control
Physical Injuries and Infections
HEALTH AND NUTRITION
Physiological R ;uii ments

Food is a fundamental human need, a basic right, and a prerequisite to good
health. The human body depends on the energy, protein, vitamins, and miner-
als that are found in a variety of foods to survive and remain strong. Studies in
Europe in the 1920s showed that in general the poor were short, thin, and suf-
fered from ill health. Their health improved and children grew taller if they were
given a diet rich in protein, energy, and vitamins. This diet became the standard
for good health and the "balanced diet" became common terminology. A bal-
anced diet could be guaranteed if people ate a plentiful and varied supply of dif-
ferent foods—for example, protein foods derived from animal products or soy-
beans, energy foods rich in carbohydrate or fat, and protective fcods, such as
vegetables and fruits, that are rich in vitamins and some minerals.
A variety of nutrients are required by humans to maintain healthy meta-
bolic function. The primary component of our diet is energy, expressed as calo-
ries or joules. Energy requirement is the amount of energy needed to maintain
health, growth, and an appropriate level of physical activity. Although the num-
ber of calories required varies greatly among individuals, depending on their
size, age (all of which influence basal metabolic rate), and level of physical ac-
tivity maintained, it is commonly based on balancing intake with output. If en-
ergy intake and expenditure are not in balance, this imbalance will result in
changes in body mass. The conditions of being underweight or overweight both
have adverse effects on human health. The health effects of malnutrition and
specific deficiency disorders are described below. Obesity, defined as a state char-
acterized by excess body fat, is a common cause of severe morbidity and
diminished longevity. An association has been found between obcsily and hy-
pertension, diabetes, the formation of gall stones, breast cancer, and en-
dometrium cancer. Table 7.1 outlines the basic nutrient requiremcnts and their
most common food sources.
Food and Culture

For many years industrialized countries have maintained guidelines for healthy
eating. In North America these guidelines are based on the principle of choosing
a variety of foods from the basic food groups, including grain products, fruits and
vegetables, milk products, and meats (or their alternatives) to enstire intake of
FOOD AND AGRICULTURE 243

TABLE 7.1
NUTRIENT REQUIREMENTS, RECOMMENDED AMOUNTS, AND SOURCES -
Nutrient Recommended Amount Common Food Sources -
Carbohydrates 50%_60% of daily energy SUGARS

(sugars and complex intake: (recommended total Fruits, vegetables, honey, milk
carbohydrates) energy intake: 7-14 MJ or
COMPLEX CARBOHYDRATES
1700-3 300 kcal, depending
Grains, legumes, root vegetables,
on age, sex and weight)
liver, fruits, vegetables
Lipids 30% of energy (saturated fats SATURATED FATS/TRANS FATTY
and/or trans fatty acids should ACIDS
be <10% of total energy: Animal fat, butter, vegetable
polyunsaturated fats should shortening
be emphasized)
POLYUNSATURATED FAT
Vegetable oil, milk, fish
Proteins 0.86 g/kg body weight daily Meat, dairy products, eggs, legumes,
(approximation) grains
Electrolytes SODtUM
(sodium, and - Salt, baking powder and soda,
potassium) meat, poultry, fish, and eggs
and water
POTASSIUM
Fruits, vegetables
VtTAMINS
Biotin No specific recommended amount Ubiquitous
Folate No specific recommended amount Dark green leafy vegetables, meat,
fish, poultry, eggs, whole grain
cereals
Pantothenic acid No specific recommended amount Ubiquitous
Niacin 2 mg/bOO kcal Meat, poultry, fich, dark green

leafy vegetables, whole grain
cereal
Riboflavin/Vitamin B 2 0.5 mg/1000 kcal Meat, poultry, fish, dairy products,
eggs, whole grain cereal, dark
green leafy vegetables
Thiamine Vitamin B 1 0.4 mg/1000 kcal Meat, poultry, legumes, whole
grain bread, milk, eggs
Vitamin A No specilic recommended amount I.iver, milk, dark green leafy
vegetables, deep yellow fruits
and vegetables
Vitamin B 6 15 zg/g protein Meat, whole grain cereal, legumes
Vitamin B 12 No specific recommended amount Meat, fish, eggs, dairy products
Vitamin C 60 mg/day Citrus fruits, tomatoes, raw green
vegetables, some meat, poultry,
legumes, whole grain bread,
milk, eggs
Vitamin D No specilic recommended amount Fortified milk, fish, sunlight
Vitamin F No specific recommended amount Vegetable oil, whole-grain cereal,
legumes, dark leafy vegetables
(continued)

eIitliZU,''I)
Nutrient Recommended Amount Common Food Sources

Vitamin K 1.5 ig phylloquinonefkg/day Green lealy vegetables, small
amounts found in meat, dairy
products, cereals, and fruit',
MINERALS
Calcium Dairy products, (lark green

vegetables, seafood
Chromium - Cheese, legumes, nuts
Copper - Ubiquitous
Fluoride Fluoridated water, seafood
iodine - Shellfish, saltwater fish, iodized salt
iron -- Meat, fish, poultry, eggs, whole-
grain cereals, green vegetables,
dried fruits
Manganese - Ubiquitous
Magnesium - Ubiquitous
Phocphorus - Dairy products, meat, poultry, fish,
legumes, whole grain cereals
Selenium - Whole-grain cereals, meat, dairy

products, poultry
Trace elements (moly- - Variety of vegetables, or seafood
bdenum, silicon,
boron, nickel,
vanadium, arsenk
Zinc - Plant and animal protein
Source: I-IWC, t )90
all essential nutrients. These food groups are considered arbitrary by some in-
vestigators, and there is controversy about alleged cultural biases in the recom-
mendations. Many people do not consume products from each of these groups
and yet are still in good health. As Table 7.1 indicates, there is a great deal of
flexibility when choosing foods that give all the nutrients required. Box 7.1 out-
lines an example of feod consumption that differs radically from the North Amer-
ican model while still providing everything a person requires. Apart from the cul-
tural influences on the dietary composition, factors such as availability, taste,
smell, appearance, cost, and convenience are important determinants of food
choice.
Effects of Nutritional Deficiencies on Health

Following Woild War 11, protein-energy malnutrition was recognized as a seri-
ous health problem throughout the developing world. Simultaneously, it was
recognized that communicable diseases were a major cause of death and illness
and that nutritional deficiencies weakened the body's resistance to these diseases.
The WHO's Panel on Food and Agriculture outlined a number of specific nutri-
tional deficiencies that remain widespread today, usually because of local envi-
ronment conditions. These are listed below.

BOX 7.1
Inuit Diet
The Inuit are an indigenous people living in northern North America. Their tradi-
tional diet consists mainly of sea mammals (seal, walrus, whale, polar bear), cari-
bou, and marine fish, with occasional berries and shellfish. This diet is high in pro-
tein and also has high amounts of polyunsaturated lipids (from the phytoplanktori
consumed by the fish). It has very low levels of carbohydrates and relatively high
levels of overall fats, exceeding the recommended amount. Despite these problems
and the limited variety in their diet, the Inuit have traditionally experienced good
health. Studies of the composition of their marine diet indicate that the animals are
extremely rich food sources providing all of the required vitamins and minerals that
normally would be achieved only by combining a wide variety of fruits and veg-
etables. It is gradually becoming clear that native foods can provide all nutritional
needs without supplementation.
Iodine Deficiency Disorders Iodine deficiency disorder is a serious affliction in

many parts of the world. The Andes, Alps, Great Lakes basin of North America,
and the Himalayas are particularly deficient in iodine, although some coastal ar-
eas and plains may also be deficient. The most clinically obvious effects of iodine
deficiency are goiter and cretinism. Mild iodine deficiency can lead to less obvi-
OUS conditions such as delayed mental development, reduced intelligence, and
diminished work capacity. Some foods, called goitrogens (e.g., cassava in central
Africa), interfere with the normal uptake and metabolism of iodine from other
foods.
Iodizing salt supplies is very effective in controlling endemic goiter, but there
are few other practical means of increasing iodine intake. There is some evidence
that goiter is increasing in Europe where people are trying to reduce their salt
intake. In those areas where intake of iodine from sources other than salt is low,
a coordination of policies is needed to control goiter through the iodination of
salt without disrupting the control of hypertension by limiting salt intake.
Vitamin A Deficiency Vitamin A deficiency leads to a serious eye disease called

xerophthalmia and sometimes to blindness. It also decreases resistance to disease
and infection and increases child mortality. The availability of vitamin A is lim-
ited in some geographic areas and is exacerbated by a diet low in vegetables. In
Asia this is a particular problem because the population exceeds the overall avail-
ability of vitamin A. Low-fat diets for the prevention of cardiovascular disease
are becoming more widespread but if fat intake is too low, it will interfere with
intake of vitamin A. By contrast, high dietary supplementation with vitamin A,
particularly during pregnancy, may also cause adverse health effects (see Box 7.2
and Fig. 7.1).

BOX 7.2
Vitamins and Health
Traditionally, health risks related to vitamins are associated with deficiencies. How-
ever, the relation between health and the intake of vitamins shows an optimum.
Excessive vitamin intake, either through diet or through high supplementation, may
result in toxic effects. The margin between physiological need and toxic dose is dif-
ferent for two distinct groups of vitamins: lipophilic (fat-soluble) vitamins (A, D, E,
and K) and hydrophilic (water-soluble) vitamins (vitamins B and C, biotin, niacin,
pantothenic acid, and folate). For the lipohilic vitamins this margin may he rela-
tively narrow compared to that of the water-soluble vitamins. Whereas vitamin A
deficiency may cause xerophthalia or (night) blindness, high doses of vitamin A may
result in several other adverse health effects including headache, vomiting, liver
damage, and hone abnormalities (see Fig. 7.1 for the health effects of vitamin A de-
ficiency and high dosage). Furthermore, a high incidence of spontaneous abortions
and birth defects has been observed among fetuses of women receiving therapeu-
tic doses of 500 to 1500 rg of 13-cis retinoic acid per kg body weight. Although the
natural content of the diet is not likely to induce toxic effects, it is increasingly im-
portant to regulate the standards set for vitamin intake because of the trend toward
vitamin supplementation and the use of vitamins as naturally occurring antioxi-
dants in food processing. This is most relevant for the lipophilic vitamins A and D
since they may accumulate in the body during long-term consumption of high doses.
- *
Iron Deficiency Anemia is a widespread and persistent problem. Iron is neces-

sary to make blood hemoglobin and is present in the oxygen-carrying red blood
cells. Most iron-deficiency anemia in developed countries is the result of iron loss
from the body because of internal bleeding. Women are at much greater risk be-
cause they lose iron from blood loss during normal menstrual cycles. In some
parts of the world, however, the iron intake is also deficient and cannot replace
the iron in women or provide sufficient iron stores in children. Certain parasites
death
hepatotoxicity
bone factures
> hemorrhages
0 alopecia
0 eczema
night normal
ness
>
0 keratinization
0
Figure 7.1 Clinical symptoms death
as a result of vitamin A defi-
ciency and from vitamin A
10 100 1,000 10,000 100,000
toxicity. From Rutten, 1997
with permission. vitamin A intake jig I kg body wt I day

also rob the body of iron. Africa and Southern Asia have particularly high lev-
els of iron-deficiency anemia due to a combination of low intake, poor absorp-
tion, and parasite diseases. The availability of dietary iron for absorption is af-
fected by both the form of iron and the nature of the foods eaten. The absorption
of some iron compounds is strongly influenced by the presence of other factors
in the food. Ascorbic acid (vitamin C) and animal foods are known to promote
iron absorption. When either of these constituents is missing, a diet based on ce-
reals and legumes may provide only a low level of iron even though the plant
foods themselves are rich in iron. Dietary iron intake and low iron stores in the
body interact with lead and cadmium intake. Iron deficiency can thus contribute
to increased lead and cadmium absorption.
Calcium Deficiency Calcium deficiency causes osteoporosis. Osteoporosis literally

means "porous bones" and can be defined as a disorder of bone metabolism in
which bone mass has been reduced to such an extent that the person is at in-
creased risk of fractures. A shortage of calcium and probably of protein during
the growth spurt may contribute to the development of osteoporosis later in life.
In addition, the causation of osteoporosis is related to disturbances of the (hor -
monal) regulatory systems involved in the maintenance of bone mass as well as
extracellular calcium concentration. Postmcnopausal osteoporosis is the most
common form of this disease. At the age of 65 years, 25% of all women have
some sign of osteoporosis; at age 85 this amount goes up to 50%. Apart from
calcium-deficient diets, the main factors involved in the loss of bone are en-
docrinological disturbances, the use of corticosteriods, gastrointestinal malfunc-
tion, and lack of physical stress to the skeleton. Cadmium and calcium interact
so that a high cadmium intake reduces calcium absorption and increases risk of
osteoporosis and a low calcium intake increases cadmium absorption and the ef-
fects on bones from cadmium exposure.
Other Deficiencies Other nutritional deficiencies are also widespread in some ar-
eas of the world. Fluoride deficiencies can lead to dental caries. Rickets and other
bone abnormalities are attributable to a combination of insufficient exposure to
sunlight and lack of vitamin D in the diet, causing calcium disorders similar to
osteoporosis. Ascorbic acid deficiency still occurs in some drought-affected areas,
particularly Africa. Vitamin B 12 deficiency can cause anemia and neurological
disorders. People on vegetarian diets that contain no food of animal origin are
particularly at risk for B 12 deficiency.
FOODBORNF DTSFASFS AND FOOD POISONING
Foodborne illnesses are a common and serious health problem. Statistics under-
estimate the number of cases of foodborne illness because not everyone affected
visits a doctor, and doctors may not report all cases to public health authorities.
Some cases of foodborne illness may not be documented because they are not
recognized as such. In various developed countries up to 60% of cases may be
caused by poor food handling techniques and by contaminated food served in
food service establishments. Similar problems exist in the developing world.

Chemical food safety and microbiological food safety are similar but separate
issues. Basically, food is a mixture of chemicals (including nutrients), natural tox-
ins, contaminants, and additives. The nutrients account for over 99.9% of the
food. Some of these nutrients may also cause adverse health effects in unbalanced
diets, as discussed in the previous section, Health and Nutrition. Biological con-
taminants, additives, chemicals, and radiation will be the focus of this section.
Foodborne biological toxins can originate from two sources: either they are a
naturally occurring constituent of the food or they arc produced by microorgan-
isms present in or on the focd. In the course of evolution, humans have learned
through trial and error to select foods that do not cause acute adverse health ef -
fects. However, the presence of toxins of microbial origin is not always easy to rec-
ognize. Illnesses related to consumption of focds that are contaminated in this way
are referred to as food poisoning. These illnesses require bacterial growth and toxin
production in the food and not in the individual. If the produced toxin is heat re-
sistant, food preparation will not affect the health risks involved.
Natural toxins in food can be acutely toxic. A classic example is ciguetera
toxin, a common toxin made by algae in the ocean and contained in the flesh
of certain fish that consume the algae. When eaten by humans, the toxin causes
severe illness. Natural toxins include venoms and other poisons produced by an-
imals for defense and to capture prey. However, many plants also produce nat-
ural toxins in abundance for protection after injury, healing, and defense. Some
of these natural products are highly toxic, some of them mimic estrogenic hor -
mones, and some are even carcinogenic. The Nobel prize—winning biochemist
Bruce Ames has estimated that the daily human consumption of natural plant
toxins may exceed the intake of industrial or synthetic chemicals in almost all
societies. Other natural toxins develop when plants are contaminated with fungi
that produce toxins, such as peanuts (ground nuts), which always contain small
quantities of aflatoxin produced by fungi. But the role of these natural toxins in
causing disease, specifically cancer, is very controversial. Ames has argued that
the risk of cancer arising from consumption of natural toxins is much greater
than the risk associated with exposure to pollutants in the environment, but not
all scientists in the field are yet convinced of this (Ames and Gold, 1990).
In contrast to food poisoning, foodborne infections depend on the transfer of
viable microcrganisms to an individual and the subsequent distribution and mul-
tiplication within the human body. The risk of food poisoning as well as food-
borne infection is considerably reduced by use of additives aimed at the preven-
tion of microbial spoilage. However, such spoilage can also be avoided by storage
of foods at low temperature (refrigeration), proper preparation of the foods, and
reduction of the storage time.
Many of the foodborne diseases discussed in this section are an indirect re-
suit of pathogens in a community's water supply. Any consideration of food-
borne diseases, particularly those of a microbiological nature, should be done
concurrently with a consideration of waterborne illnesses.
Substances are also added intentionally to foods to improve their appearance,
texture, flavor, and nutritional value. Although the use of food additives is gen-
erally strictly regulated and their effects on human health may generally be con-
sidered to be beneficial, serious health effects such as allergic reactions have been

attributed to these chemicals. Food contamination can also occur through the
use of sewage or improperly treated wastewater for irrigation and/or as fertilizer.
Potentially toxic chemicals, for example, those used in agriculture, can find
their way into food products, as can insecticides used in the home. These envi-
ronmental contaminants of both biological and chemical origin will be discussed
in more detail below. In addition, physical contaminants (e.g., glass, pieces of
metal) must be considered, as these may he inadvertently introduced during food
processing.
Biological contaminants
Biological hazards in food that are of concern to public health include pathogenic
strains of bacteria, viruses, parasites, helminths, protozoa, algae, and certain toxic
products they may produce (WHO, 1992b). The following four categories sum-
marize the concerns about biological contaminants.
Bacterial Contaminants Biological hazards may act through two general mech-
anisms in causing human illness. One mode of action is the production of tox-
ins that may cause adverse health effects ranging from mild symptoms of short
duration to severe intoxications that can be life threatening or induce long-term
health consequences. These toxins arc complex enzymes that can destroy pro-
tein and tissues. The second mode of action is the production of pathological re-
sponses that result from ingestion of viable organisms capable of infecting the
host (see Box 7.3). Generally, for foodborne illness to occur, one of the follow-
ing events must take place: (1) bacteria present in the original food source sur-
vive food production, including harvesting, storage, and processing stages; (2)
bacteria enter the food preparation area via the food source or food handler and
contaminate other foods that are ready to eat; (3) (bacteria in food multiply and
are present in sufficient quantities when consumed; and (4) bacteria produce a
toxin when they multiply and a sufficient level of the toxin is present.
In the case of food poisoning induced by bacterial toxins, threshold levels of
concern are much easier to establish than with illnesses resulting from infections.
Dose—response data can be obtained and health risks can be assessed by follow-
ing the quantitative risk assessment paradigm proposed for chemicals (see Chap-
ter 3). To characterize risks from invasive strains of pathogenic bacteria, how-
ever, dose—response data only apply to the quantity of bacteria needed to start
an infection, and this may vary for the following reasons:
• host susceptibility to pathogenic bacteria is highly variable (e.g., infants, the

elderly, or undernourished people are more susceptible to foodborne illness
than healthy adults)
• attack rates from a specific pathogen vary widely
• virulence of pathogenic species is highly variable
• pathogenicity is subject to variation resulting from frequent mutation
• antagonism from other bacteria in foods or the digestive system may influence
pathogenicity
• food composition will modulate the ability of bacteria to infect and/or other-
wise affect the host.

BOX 7.3
Bacteria Causing Foodborne Infections and Food Poisoning
SA LMONELLAE
The bacteria may reach food either directly or indirectly through such channels as
animal excreta, human excreta, or water polluted by sewage. The symptoms include
diarrhea, abdominal pain, vomiting, and fever. In recent years the contamination
of poultry has been a major source of salnionellosis. Other incriminated foods in-
clude dairy products, shellfish, and vegetables. This is a classic example of a food-
borne infection.
STAPHYLOCOCCI
Foodborne illness due to staphylococci depends on the presence of sufficient toxin

in the food. The source of the staphylococci is often food handlers with skin infec-
tions e.g., boils). Symptoms include nausea, vomiting, abdominal pain, prostration,
dehydration, and subnormal body temperature. Incriminated foods include ham,
poultry, egg salads, produce, and cheese. This is one of the most common examples
of bacterial food poisoning.
Therefore, when assessing health risks imposed by pathogenic bacteria, a quali-

tative risk assessment may be the only feasible method.
Several bacterial diseases are communicable. These include cholera, described
in Chapter 6, and typhoid, which is characterized by fever, headache, cough, en-
largement of the spleen, and rose-colored spots on the trunk. There is a greater
risk for typhoid in areas where there is poor general sanitation and no water pu-
rification. Shigellosis is an acute bacterial disease marked by diarrhea, fever, nau-
sea, and sometimes vomiting and cramps. Humans are the reservoir of infection
and the illness is usually passed on by fecal-oral transmission.
Viral and Parasitic Contaminants Viral loodborne diseases are believed to be

more prevalent than is documented. Even if a microbiological examination of
food and water does not reveal a high number of bacteria, the food may still con-
lain pathogenic viruses. Among the most notable viral foodborne diseases is he-
patitis A. Epidemiological evidence shows that the hepatitis A virtis is spread pri-
marily throttgh food. However, beca use the incubation period is quite long
(usually 28 to 30 days), outbreaks are difficult to investigate. Symptoms include
fever, malaise, nausea, and abdominal discomfort followed by jaundice. Shellfish
from polluted areas, water, fruits, and vegetables contaminated by feces., and var-
ious types of salad prepared under unhygienic conditions have all been involved
in outbreaks.
Parasitic infections of food are difficult to investigate as little is known about
the infective dose required or the exact method of transfer to an individual. Con-
tamination may occur from hand to food or directly from polluted water. Prob-

BOX 74
Parasitic Foodborne Infections: Giardiasis and Trichinellosis
Giardiasis is generally characterized by flatulence, belching, nausea, vomiting, fa-

tigue, and cramps, caused by Giardia cysts penetrating the intestinal walls. Giardia
is often spread by feces entering water that is later used for washing food, or it may
be transferred from hand to mouth (see Fig. 7.2). The disease occurs most often in
areas where there is poor sanitation and a lack of clean drinking water. The main
preventive measure is the sanitary disposal of feces and the protection of public wa-
ter supplies.
Trichineilosis is characterized by fever, retinal hemorrhage, diarrhea, muscle
soreness and pain, skin lesions, and prostration. It is caused by the migration through
the body of the helminth (worm) Trichinel/a spiral/s. In the small intestine, larvae
develop into mature adults and mate. Female worms produce larvae that penetrate
the intestinal wall and enter the bloodstream. The larvae encyst themselves in skele-
tal muscle. Infection occurs through the consumption of raw or undercooked meat,
particularly pork (see Fig. 7.2). Preventive measures are inspection of meat in the
slaughterhouse and adequate cooking of pork.
lems arise in many parts of the world where meat and/or fish are eaten raw or
undercooked and where people drink untreated water or use it in food prepa-
ration. The best protection from parasitic diseases is a safe water supply and ad-
equate cooking and refrigeration temperatures (Jacob, 1989). Two of the most
widespread parasitic foodborne diseases are giardiasis and trichinellosis (some-
times called trichinosis) (see Box 7.4 and Fig. 7.2).
Mycotoxins Mycotoxins are secondary metabolites of fungi that can exert vari-
ous types of adverse health effects, including teratogenicity, carcincgenicity, mu-
tagenicity, as well as oestrogenic effects. At this moment several hundred myco-
toxins have been docutnented, and many of them are produced by the genera
Aspergillus. Penicillium, and Fusarium. Although toxic syndromes associated with
exposure to mycotoxins, also indicated as mycotoxicoses, have been known for
many centuries, it was not until the discovery of the aflatoxins in the early 1960s
that these dietary risk factors were fully appreciated. Mycotoxin contamination
of food items depends on the environmental conditions that may allow mold
growth and production of toxins. As with bacterial food intoxication, the absence
of live molds in foods does not imply that mycotoxins have not been produced,
or vice versa. Toxins may have been formed in earlier stages or during produc-
non or storage and, as a result of their chemical stability, may still be present af-
ter cooking or other forms of food processing. The aflatoxins, now regarded as
the most important mycotoxins, are produced by the molds Aspergillusfiavus and
A. parasiticus. Allatoxins reveal high carcinogenic activity. Before they are bio-
logically active, they have to be metabolized. Aflatoxin Bi, the most prevailing

Person eats encysted
' -- larvae in meat and
larvae encyst in F develops trichinellosis
skeletal muscle
Person infected In small intestine
larvae develops into
with giardiasis
adults and mate
Giardiasis cysts
in intestine
Encysted worms
I
in pork meat
Gia
Transfer lemolN
to mouth excreted
\
I Water used
for washing
Trichinella \Cs
spiralis
worms in ra t intcton 'Pig eats
/ rat excretions
t!;4
vegetables
Cysts cysts Trichine I/a spiralis

on hands in water worms in rats
Figure 7.2 Mode of transmission of giardiasis and trichinellosis. From Jacob, 1989, with
permission.
form, followed by Gi, B2, and G2, has been shown to be a potent hepato-
carcingen. Particularly in combination with hepatitis B virus infection, aflatox-
ins may lead to primary liver cancer. Allatoxins are produced both pre- and post-
harvest, at relatively high moisture contents and relatively high temperatures.
The fungi involved in the production grow best at approximately 25°C and with
a relative air humidity of over 80%. Aflatoxins occur on several food products,
including oilseed (groundnuts), grains (maize), and figs. Aflatoxin Ml can be
found in low concentration in milk samples. Discouraging fungal growth is the
most effective way to achieve prevention of aflatoxin contamination. Particularly,
adequate post-harvest crop drying is essential to reduce the chance of fungal
growth.
Prion Diseases Bovine spongiform encephalopathy (BSE or mad-cow disease) first

came to the attention of the scientific community in November 1986 with the ap-
pearance in cattle of a newly recognized form of neurological disease in the United
Kingdom. Between November 1986 and May 1995, approximately 150,000 cases
of this newly recognized cattle disease were confirmed from approximately 33,500
herds of cattle in the U.K. Epidemiological studies in the U.K. at that time sug-
gested that the source of disease was cattle feed prepared from carcasses of dead
cattle and that changes introduced in 1981 and 1982 in the process of preparing
cattle feed may have been a risk factor (Will et al., 1996). Speculation about the
cause of the disease appearing in the food chain of cattle has ranged from spon-

taneous occurrence in cattle (the carcasses of which then entered the cattle food
chain) to entry into the cattle food chain from the carcasses of sheep with a sim-
ilar disease.
Bovine spongiform encephalopathy is thought to be associated with a trans-
missible agent called a prion, which stands for proteinaceous infectious particle, and
is yet to he fully characterized. Prions appear to multiply in a very exceptional
way, by converting normal protein molecules into dangerous ones by changing
their shape. Prions affect the brain and spinal cords of cattle, which develop
sponge-like changes visible under an ordinary micr( scope. It is a highly stable
agent, resisting normal cooking temperatures and even higher temperatures such
as those used for sterilization, freezing, and drying. The disease is fatal to cattle
within weeks to months of its onset.
Bovine spongiform encephalopathy is one of several different forms of trans-
missible brain disease in animals. Human forms of spongiform encephalopathies
also exist. The best-known form, Creutzfeldt-Jakob disease (CJD), is associated
with a hereditary predisposition (approximately 10 0/ of cases) and with a more
common, sporadic form that accounts for the remaining 90% . Another form,
kuru, was identified in Papua, New Guinea, and appears to be transmitted by
human ritual handling of bodies and brains of the dead. Symptoms of the hu-
man prion diseases are dementia, in combination with or followed by loss of co-
ordination.
One of the conclusicns at a 1996 WHO meeting was that the risk of trans-
mission of BSE to humans could he minimized if certain measures were under-
taken in the U.K., including the handling and composition of offal in cattle feed
given to cattle for consumption, and precautionary measures at farm, slaughter,
and meat-processing levels. The meeting also recommended that the WHO en-
courage research on BSE and its possible implications for public health and con-
tinue to provide guidance to countries to minimize the risk of transmission of
BSE and of human diseases such as CJD through medical procedures (WHO,
1996).
Chemical Contaminants
There are many sources of chemical contaminants (see Fig. 7.3). Vehicle exhausts
and emissions are a common cause of air pollution, and hazardous airborne el-
ements can be deposited onto and absorbed into various crops. Industrial and
mining activities that produce poisonous wastes can contaminate plant and soil
alike. Because of the complex interrelationships between air, water, land, and
plants, the contamination of any one element—from, for example, a chemical
leak or a nuclear accident—will have serious implications for the others. Contam-
inants are often found in animals, particularly as a result of modern farming
methods. Drugs used to prevent disease and promote growth in these animals
have to be carefully regulated to ensure that levels in meat are safe for human
consumption.
Contamination can also occur during food storage. Coatings containing poly-
chlorinated biphenyls (PCB5) have been used inside silos and have resulted in
high levels of PCBs in milk. Food processing allows another potential period for
chemical contamination. Some processing plants have witnessed instances of heat

Q4~i :Y -
F
vehicle emissions
(lead)
cu
crops
processing
(cadmium,
agricultural practice1.J.. lead, PCBs)
(pesticides, cadmium, p p
PCBS) f114 cooking
livestock
LJ L I
landfills (PCBs, lead)
storage
seafood (aflatoxins)
industrial
emissions and
effluents (lead,
cadmium, mercury, PCB5)
Figure 7.3 Pathways to food for selected chemical contaminants. From UNEP/GEMS. 1992,
with permission.
exchangers, transformers, and capacitors containing PCB-based fluids leaking and

contaminating food. Both commercial and domestic cooking utensils have been
detected as sources of lead and cadmium in foods. Lead-based solder used in food
tins is the major source of lead in canned foods (UNEP/GEMS, 1992).
The Global Environmental Monitoring System (GEMS) Food Contamination
Monitoring Program was established in 1976 to monitor and report levels and
trends of food contaminants worldwide. About 40 countries submit data from
national food-monitoring programs; the choice of foods and contaminants that
are monitored vary from country to country. From 1971 to 1988, 19 contami-
nants were monitored through the program. The chemical contaminants that
caused the most concern from 1980 to 1988 and the results of the GEMS/UNEP
program are described below. (Pesticides were also included in the monitoring
program, they will be discussed in Environmental and Occupational Health Haz-
ards, below.)
Polychiorinated Biphenyls Polychiorinated biphenyls are fluids that were widely

used in electrical transformers, heat exchange fluids, and hydraulic systems. They
have other industrial uses and were, for example, added to paints, copying pa-
per, adhesives, and plastics to improve their flexibility. Commercial production
of PCBs began in the 1930s but has been drastically restricted in some countries
since 1970 when their toxic effects were determined. Contamination of edible
oil with PCBs led to large-scale poisoning in Japan in 1968 and Taiwan in 1979.
The PCBs are known to suppress the immune system and to induce neurotoxic
effects and developmental disorders. Furthermore, studies on exposure to PCBs
in the workplace suggest that they may also present a carcinogenic risk to hu-
mans. No tolerable intake levels have been established for PCBs internationally,
although some countries have drawn up national limits for food products. The
PCBs are rarely detected in vegetables, vegetable oils, fruits, eggs, or cereals, al-

1.00
0.07
0.06 Japan
p.9/kg
0.05
\/ \"
bw/day d
0.04
\ /
/
0.03
United States
0.02
0.01
Figure 7.4 Average daily intake of
PCBs in adults in the United States
1977 1979 1981 1983 1985 1987 and Japan (p.g/kg bodyweight/day).
From UNEP/GEMS, 1992, with per
Year n-li SSI ()fl.
though there have been reports of high levels in some breakfast cereals, a result
of contamination by packing materials. Generally, of all types of foods monitored,
fish contain the highest levels of PCBs. As a result, diets consisting of high lev-
els of fish consumption may have a high PCB intake, as seen in Figure 7.4, which
shows the difference between average dietary intake of PCBs in the United States
and that in Japan, where large amounts of fish are consumed.
Polybrominated Biphenyls Polybrorninated biphenvis are compounds similar to

PCBs that were extensively used in the past as fire retardants. In 1973, bags of
PBB (the hexabromobipheny1) were added to animal feed at a dairy farm in
Michigan. The mistake was caused by a mistake in packaging; the same plant
produced both. Dairy cattle ate the ctntaminated feed and their contaminated
milk was widely distributed to people in the region. The PBBs were later iden-
tified as possible carcinogens.
Lead Lead produces adverse effects on blood forming tissues, the digestive and
nervous systems, and the kidneys (also see Chapter 2). Lead is naturally present
in the soil and is introduced into the environment through industry and through
exhaust fumes of leaded gas used in vehicles. Lead is found in batteries, solder,
dyes, and insecticides and can be transferred to food either directly through per-
sonal contact or indirectly through environmental contamination. Lead may be
present in drinking water where lead pipes are used for domestic plumbing or
where lead-based solder is used on copper pipes. It may also he found in the
enamel used for kitchenware, in the glazes used for pottery, and in the solder
used for cans containing food or drink.
Fish and shellfish generally have a higher concentration of lead than other
foodstuffs; however, in regions where there is extensive industry and mining,
vegetables also show significantly high concentrations. Vegetables, grains, and

fruit exposed to heavy vehicle exhaust or industrial emissions also contain higher-
than-normal lead concentrations.
Because lead accumulates in bone, tolerable levels of consumption are given
as a weekly figure to limit intake on a long-term basis. This level is known as
the provisional tolerable weekly intake (PTWI) and is expressed as micrograms of the
chemical per kg of body weight. The PTWI of lead is 50 pg/kg of body weight
for adults and 25 .tgIkg for children (see Chapter 3 for discussion of acceptable
daily intakes ADIsl).
Cadmium Cadmium is a cumulative poison that affects the kidneys even at rel-
atively low levels of exposure. It also affects placental function, liver function,
testes, and formation of bone tissue. In addition, cadmium is a suspected human
carcinogen. The main sources of cadmium in foods are industrial emissions and
fertilizers. In Japan in the 1950s a number of areas with cadmium-contaminated
rice were identified, and similar problems have been found more recently in
China. Other potential sources of cadmium in food are kidneys (especially from
animals that roam wild), cadmium-lined metal equipment used in commercial
food processing, kitchen enamel, pottery glazes, and some plastics.
The established PTWI for cadmium is 7 pg/kg body weight. Data show that
average levels were lowest in dairy products, vegetables, fruit, cereals, meat, and
fish, whereas a sharp increase in cadmium concentration was found in molluscs
and crustaceans and in animal kidneys. Populations in industrial areas showed
significantly higher concentrations of cadmium in their bodies.
Mercury Mercury has been used for many centuries and is still commonly used
today. It can be found in thermometers, batteries, fluorescent lights, and in many
industrial processes including the production of fungicides and paints. Mercury has
toxic effects on animals and people. Pregnant women, nursing mothers, and chil-
dren are particularly susceptible to mercury poisoning. The most toxic form of mer-
cury is methylmercury, which causes damage to the central nervous system.
The PTWI for mercury is 5 [hg/kg body weight, of which no more than 3.3
gfkg should be methylmcrcury. Methylmercury is often found in fish because
of the industrial effluents containing mercury that are discharged into rivers or
seas and converted by bacteria into methylmercury (see Box 7.5). The Mediter-
ranean area accounts for half the world's production of mercury and accordingly,
mercury levels in fish from this area have been found to be very high. (Aston et
al., 1985; Bosnir et al., 1999)
Other areas of naturally high mercury discharge are the mid—north Atlantic
ocean and some river systems in North America. Some tributaries of the Ama-
zon have been contaminated by mercury from the use of the metal in gold ex-
traction in primitive gold mining operations. Flooding caused by hydroelectric
dams is another source of increased levels of mercury in fish (see Chapter 11,
Deforestation and Descrtification).
Radioactive Contaminants
On the basis of the non-threshold concept, radionuclides may present carcino-
genic, mutagenic, and teratogenic hazards. Several radionuclides have special,

BOX 7 S
Mercury Poisoning in Minamata, Japan
Poisoning from organic niercurial compounds results in a wasting brain disease and
lcss of control of the motor nerves. This form of poisoning became known as Mi-
namata disease because one of the worst outbreaks occurred in Minamata, Japan in
the early 1950s. This outbreak alerted the world to the dangers of chemical conta-
nhination.
People in the small fishing town suffered progressive weakening of the muscles,
loss of vision, and eventual paralysis and coma. Minamata seabirds and household
cats that, like the fishermen and their families, subsisted on fish also showed signs
of the disease. Several hundred people__40% of those affected—died, and others
suffered from permanent damage from the poisoning.
Concentrations of metbylmercury were discovered in fish and shellfish taken
from the local bay, and in 1968 mercury was officially identified as the cause of the
poisoning. The source of the mercury compounds was traced to the effluent dis-
charged from a local chemical company.
Source. Environment Agency, 1975.
strong affinities for specific organs or tissues, resulting in a relative dose that may
be several times higher than the ingested or absorbed dose. These affinities may
result in accumulation over time. There is no detoxification or elimination mech-
anism for radionuclides except for excretion or spontaneous decay.
The radionuclides of interest in food safety are the so-called internal emitters
that enter the body by ingestion. Naturally occurring internal emitters that con-
tribute to the total radioactive dose in the diet are potassium-40, radium-226,
uranium-228, carhun-14, tritium, rubidiurn-87, lead-21 0, and polonium-2 10. In
addition to this natural radioactivity, the environment (and therefore also food)
can he contaminated with a number of human-made radioactive elements. Small
amounts of these elements may be released in the environment by emission from
nuclear reactors through their effluents (see below). Furthermore, radioactivity
may come from fallout from atmospheric testing of nuclear devices, spills from
reactor accidents, and nuclear warfare.
Since the first nuclear reactor was constructed in 1954 in the United States,
many other nuclear power plants have been built all over the world. Although
relatively small amounts of radionucleides are emitted through the effluents of
these reactors into the environment, they are generally considered to be safe. By
contrast, the release of radioactive products following a reactor malfunction or
explosion is a much bigger concern. Unfortunately, such events have occurred
on several occasions, including the accident in the Windscale reactor in the
northwest of England (October 1957) and the Three Mile Island reactor in Penn-
sylvania in the United States on March 28, 1979. Following the Windscale acci-
dent, iodine- I 31 was found in milk prodticed in the surrounding areas. (Dunser
et al., 1959). There was no contamination found in milk or other foodstuffs with

other radionuclidcs. Because of the short half-life (8 days) of iodine-fl 1, its pres-
ence in foods is only significant a few weeks alter an accidental spill. For in-
stance, 60 days after the event less than l% of the original amount of iodine-
1 31 was found in milk samples. Also in the case of the Three Mile Island accident,
some of the milk samples were found to be contaminated with iodine-I 31 (Ad
Hoc Population Dose Assessment Group, 1979).
In cases such as a nuclear accident of the magnitude of the one in Chernohyl,
radioactive contamination can be widespread over many countries (WHO, 1995c).
The problems for public health and agriculture at a relatively large distance, re-
ferred to as the far-field, are completely different from those in the proximity of
the nuclear power plant. (Problems in the near-field are discussed in Chapter 9,
Nuclear Power). Generally, at a large distance there is relatively little deposition
of radioactivity unless the passage of the plume coincides with rainfall. There-
fore, contamination of soil and crops can vary substantially from one site to an-
other. Outside these contaminated areas, the exposure in the far-field will occur
primarily from the incorporation of the deposited radionuclides in the human
food chain.
Control of crops and animal products may have to be exercised for a long pe-
riod of time since radionuclides deposited on the ground enter the food chain
very slowly. Action can he taken to minimize the accumulation of radionuclides
in animals or animal products—for instance, by feeding with imported feed or
silage from previous seasons, or by preventing consumption of contaminated
foodstuff.
FOOl) QUALITY CRITERIA
Oi'ervieit'
The quality and safety of the food supply is a topic of continual interest to the
media and the general public. The word quality has many different meanings and
interpretations. The average consumer associates quality with personal prefer-
ences and may therefore subjectively interpret the term as indicating whether
the food is liked or disliked, good or poor. In addition to these psychological fac-
tors, sensory stimulations such as flavor, color, texture, visual appearance, and
packaging are important. Also, new developments in food supply prompt dis-
cussions about the scientific evidence for safety and the use of suitable control
measures. Food quality from a more scientific point of view also includes a num-
ber of safety aspects such as the presence of environmental contaminants, pes-
ticide residues, use of food additives, microbial contamination, and nutritional
quality. Thus, food quality is determined by four main categories of qualitative
properties: (1) organoleptic aspects (how it affects the senses; its taste and smell),
(2) nutritional value, (3) functional properties, and (4) hygienic properties. A
given characteristic of a food is often relevant to more than one of these cate-
gories. For instance, a longer shelf life is an important quality relevant to food
retailers, as it makes stock management easier. It is also of interest to consumers,
as it keeps prices lower and prolongs home storage periods. These advantages re-
fer primarily to functional properties, but they also affect the hygienic proper-

ties, for a product with a longer shelf life may present a lower risk of foodborne
illnesses.
Nutritional Value
Two types of recommendations for food intake can he employed: dietary stan-
dards and dietary guidelines. Dietari standards help to determine the amount of
a particular nutrient that is adequate for the majority of the population (sec Table
7.1). In 1943, the United States Food and Nutrition Board of the National Re-
search Council published a list of recommended dietary allowances (RDA5). These
RDAs represented the quantities of nutrients believed to be adequate to meet the
physiological needs of the majority of healthy persons in the United States. Thus,
RDAs are safe and adequate levels of nutrient intake but are neither minimal re-
quirements nor optimal levels of intake. The RDAs have now been established
by scientific committees in many countries but none of these RDAs can be ap-
plied globally because of differences in diet and culture in the various countries.
Setting RDAs is not an easy task, simply because of a lack of knowledge about
human requirements of nutrients. Therefore, different committees may reach dif-
ferent conclusions, resulting in variations in RDAs. Dietary standards such as
RDAs are used for: designing nutrition education programs; planning food sup-
plies to subgroups in the population; establishing guidelines for the nutritional
labeling of foods; developing new products in the food industry; and evaluating
the adequacy of food supplies to meet national nutritional needs.
Dietary guidelines are recommendations for an optimally balanced diet aimed at
the reduction of chronic diseases through changing dietary patterns. These dietary
guidelines are based on epidemiological studies that have attempted to identify
dietary patterns associated with a high or low incidence of diseases. The hypotheses
generated by such studies can subsequently be tested in animal studies. However,
dietary guidelines have not been very successful in modifying either consumers'
choice of food or the composition of the food supplied by the industry.
Food Safety
In practical terms, safe food can be defined as food that, after being consumed,
causes no adverse health effects. It is clear, however, that absolute safety is an
unattainable goal, and safety must therefore be defined in relative terms such
that any health risk associated with food consumption is limited to an acceptable
level. The risks must also be weighed against the need for the consumption or a
range of foods that supply nutrients sufficient for survival and good health. When
discussing the toxicological safety of foods it is necessary to discriminate between
the various kinds of toxicological risks. Natural toxins, inadvertent contaminants,
intentionally added components (additives), and new food ingredients can pose
very different kinds of risks.
Safety Standards for Natural Toxins and Food Contaminants Natural toxins and
contam-inants are undesirable and uiiintentionally present in food. These food
constituents form a large and very diverse group of chemicals, some of which
have already been discussed in previous sections. Again, acceptable intake is based
on the toxicological profile of the component in question, defined in a way sim-

ilar to that described for food additives. In the case of food contaminants, the
terms tolerable daily intake (TDI) or provisional tolerable weekly intake (PTWI) are
generally used to reflect the levels permissible in food to maintain a safe supply
(see examples in section Nutritional Value, above). In the case of carcinogens,
human exposure should be reduced to the lowest practically achievable level.
Safety Assessment of Additives and New Food Components Detailed information

about the nutrient content of stored food should be produced on the packaging
so that consumers can choose the nutritional balance of their diets. If a tradi-
tional food is produced by a new process or a new variety is produced by selec-
tive breeding, analysis of the nutrient profile should indicate to what extent the
novel food is equivalent to the traditional product. The current concern about
genetically engineered food highlights the uncertainities about the safety and ac-
ceptability of new food ingredients. New foods may contain natural toxins as well
as contaminants. In the event that new contaminants or toxins are detected, the
risk involved will have to he assessed. Even if known contaminants or toxins are
found, the levels may not exceed the acceptable levels for food.
Before a new food additive can be used, the manufacturer should carry out
a hazard identification. The results of the investigations must then be supplied
to a regulatory authority that will carry out the risk assessment in cooperation
with the company; most countries require this by law. Furthermore, the need
for the new additive should be established to ensure that consumers are not ex-
posed unnecessarily to the additional risk of a new chemical if it is of no partic-
ular benefit. If the risk is considered acceptable, the company is generally granted
permission to use the new additive, which is usually restricted to particular lev-
els in certain food products or food categories. The additive is also subject to a
form of post-marketing surveillance in which the occurrence of unexpected ef-
fects may be monitored. If new information about the safety of the additive is
obtained, its use must be reviewed.
It is beyond the scope of this chapter to give a review of the requirements for
the safety assessment of new food components. In principle, a number of actions,
including literature research and additional research, must he taken in this as-
sessment, which should result in the determination of a dose—response relation-
ship for any possible toxic effect of the new food additive. Subsequently, the risk
assessment is carried out by determining the no-observed adverse-effect level
(NOAEL), which is the highest dose in the most sensitive animal species that
causes no toxic effects. The NOAEL is then divided by a safety factor to set an
acceptable daily intake (ADI) level (see Chapter 3).
Regulatory Authorities and Standard Setting

National regulatory authorities are responsible for focd safety standards, thus in
principle, every country can have its own standards. To achieve the acceptance
of food standards across national boundaries, many countries adopt values pro-
posed by international bodies such as the WHO and the Food and Agricultural
Organization of the United Nations (FAO). Through the International Program
on Chemical Safety (IPCS), the WHO, UNEP, and FAO play a guiding role in the
international procedure of evaluating risks from chemicals and setting levels of

tolerance for residues of chemicals in food. Two joint committees of the WHO
and FAQ function as scientific advisory bodies of what is known as the Codex
Alimentarius Commission: the Joint Expert Committee on Food Additives
(JECFA), which evaluates focd additives, food contaminants, and residues of vet-
erinary drugs; and the Joint Meeting on Pesticide Residues (JMPR), which eval-
uates pesticide residues on the basis of toxicological and biochemical data and
proposes maximum residue limits (MRLs). The Codex Alimentarius Commission
has the following goals:
• prctection of the health of the consumer and the safeguarding of fair practice
in food trade
• coordination of all food regulatory activities carried out by international gov-
ernmental and nongovernmental organizations
• establishment of priorities for the preparation of provisional standards
• finalizing of provisional standards that will be published in a Codex Alimen-
tarius
• amendment of already published standards, if necessary.
The Codex standards (FAQ/WHO, 1989) have been shown to be of great value
in bringing food standards into accord, even though the Codcx standards have
no legal status (see Box 7.6). The Commission's system is unique in that it pro-
vides industry leaders the possibility to participate in pre-Codex meetings and to
join the debate, although industry representatives have no voting rights in these
meetings. Furthermore, industry representatives are offered the opportunity to
comment on decisions made about safety evaluation during specially organized
JECFA, JMPR, or European Community (EC) hearings.
The harmonization of food standards is also one of the objectives of the EC.
Within the EC the safety evaluation of food additives or other substances in food
is formally carried out by several working groups of the Commission of the Eu-
ropean Communities. Once a proposal is enforced by the Council of Ministers,
it is mandatory for the regulatory authorities in the member countries.
FOOD QUAlITY ASSURANCE
To ensure high quality of the food supply, a number of parties must play spe-
cific roles. The main actors include the government, consumers, and the food in-
dustry. The government is responsible for the establishment of standards or codes
of practice as well as the enforcement of laws and regulations. Furthermore, it
should encourage the food industry to undertake voluntary measures to improve
fcod safety, such as providing advice and guidancc. Consumers in turn should
be well aware of the quality of the food they buy, prepare, and consume and
should adopt appropriate practices of food handling at home. At the industry
level, all segments, including agriculture, should establish some systcm for safety
assurance of their products and employ appropriate procedures and technologies.
The flow of raw food materials to actual consumption is schematically pre-
sented in Figure 7.5, including the accompanying hazards and risks. In principle,
the same flow scheme applies to both the food indusiry and to locally produced

BOX 7.6
Thailand: A Success Story for Food Standards and Export
Like many developing countries in tropical regions, Thailand has had a great po-
tential for improving its food export business. This Southeast Asian country grows
pineapple and other tropical fruits, cashew nuts, mans types of mushrooms and
baby corn. It also harvests shrimp and other marine products, and its rice is con-
sidered by man't to he the best in the world. Since the establishment of its National
Codex Alimentarius Committee in 1969, Thailand has seen its food export grow
nearly 12-fold to more than U.S. $4000 million. However, the growth has been hap-
hazard: exports increased by about 30°c between 1980 and 1981 but then dropped
back to less than the 1980 level for the next 4 years as food products were contin-
ually rejected by foreign countries. Noting that products were being refused because
of contamination and improper labeling, the country called upon the Food and Agri-
cultural Organization (FAQ) and the United Nations Development Program for help.
Experts from the FAQ were sent to the country, as they often are upon request. Us-
ing Codex Alimentarius standards and guidelines, they set up a pilot export control
program, trained inspectors, designed voluntary inspection systems, and brought in
laboratory people to train Thai workers. Video programs were developed for train-
ing projects, and a Memorandum of Understanding ensuring inspection and certi-
fication procedures for monitoring and sampling was signed with one of the world's
major importing countries. At the same time, WHO experts assisted Thailand in
building up its domestic food safety capabilities. Thailand's food exports grew from
U.S. $2000 million to U.S. $4800 million between 1985 and 1989, contributing
greatly to the country's 10% economic growth rate during the period
Source. (FAÜ/ WHO, 1994).
foods for private consumption, although in the latter case the food processing,
storage, and transport stages will be relatively short. In such a situation, adequate
monitoring of food quality is usually more difficult to achieve. All steps in this
process and possible preventive measures for ensuring food quality at various
stages are briefly presented here.
Production of Raw Materials

To ensure safe mod production, it is important to look at the agricultural level
and improve the hygienic quality of raw foods. By improving the conditions un-
der which animals are raised, the hygienic quality of raw food products can be
significantly improved. Furthermore, use of both pesticides and fertilizers should
be reduced, and residue levels of toxic chemicals used to improve crop produc-
tion should be systematically monitored. Food safety at this stage can also be im-
proved through measures aimed at reduction of industrial and vehicle emissions
and disposal of hazardous waste materials that can enter the food chain.
Biotechnological methods can he used to develop crops that are more resis-
tant to pests and thereby decrease the need for pesticide use. However, such gc-

Hazards:
Production of nutrients
Raw Materials natural toxins
microbial toxins
• environmental contaminants
Hazards:
Food reaction products
Processing • contaminants
I • additives
Hazards:
Storage chemical contamination
and Transport • microbial contamination
Hazards:
Food • chemical contamination
Preparation • microbial contamination
Risks:
Food • intoxication by chemical contaminants Figure 7.5 Flow scheme of
Consumption • foodborne infections food production to food con-
food poisoning
sumption.
netically engineered foods may include new toxins and the plants may grow in
uncontrolled ways creating new weeds. More research on the safety of these ge-
netically engineered crops is needed. These biotechnological methods for food
production have been challenged on ethical grounds, as genetic engineering can
he seen as the development of unnatural plant species with unpredictable eco-
logical consequences.
Food Processing
Greater demands are being made on the food-processing industry as a result of in-
creasing urbanization. As consumers continue to move further away from the
sources of production, they will require an effective and safe food distribution sys-
tem. This separation of the consumer from the production sector also means a loss
of the traditional methods used by the consumer to ensure the safety of food.
Substantial losses of food by contamination and spoilage can be prevented
through the use of carefully controlled technology and well designed food pro-
cessing infrastructure. In addition, modern technologies can he used to prevent
or reduce the formation or use of chemicals in food. For example, crops can be
dried to prevent mold growth and production of mycotoxins during storage. Ir-
radiation can replace the use of potentially harmful chemicals used for disinfec-
tion and inhibition of sprouting. Traditional approaches to food safety, hygiene,
protection, and sanitation have their limitations and do not always guarantee re-
ductiori to the desired level of reported foodborne diseases, even in developed
countries. The potential formation of reaction products from irradiation has not
been fully investigated, however, and new health risks cannot be entirely ex-
cluded.

TABLE 7.2
HAZARD ANALYSIS AND CRITICAL CONTROL POINT
(HACCP) SYSTEM
Determine hazards and assess their severity and risks
Identify critical control points
Institute control measures and establish criteria to ensure control
Mon it r critical control points
Take action whenever monitoring results indicate criteria are not met
Verity that the system is tttnctioning as planned
Son rn. B rca ii, 1989,
The mainstay of microbiological food safety programs has been inspection. In-
spection programs have serious limitations, however, as they sometimes over-
look critical factors that are not part of the inspection protocol. Inspection ser-
vices are usually inadequate or nonexistent in developing countries, where
inspectors, scientists, and regulatory authorities arc sorely lacktng. Industrialized
countries need to standardize regulations to ensure the free flow of food among
all the countries of the world (WHO, 1992b).
A different approach to safety in mcdern industrial food production is the
Hazard Analysis and Critical Control Point (HACCP) system, which is attempt-
ing to make a significant impact on the prevention of Ioodbornc diseases. The
HACCP system consists of a series of interrelated actions that should be taken to
ensure the safety of all processed and prepared foods at critical points during the
stages of production, storage, transport, processing, preparation, and service. The
elements of the HACCP system are summarized in Table 7.2. The applications of
this system are discussed in Microorganisms in Food (1988 International Commis-
sion on Microbiological Specifications for Food, the Hazard Analysis Critical Con-
trol Point Manual published in 1989 by the Food Marketing Institute of the U.S.
Bryan, 19891, as well as in a WHO report, Bryan, 1992).
Food Preservation and Storage

The aim of food preservation is to eradicate or prevent the growth of harmful
pathogens during manufacturing so that food will remain safe to eat for longer
periods of time. Bacterial growth is enabled by a number of conditions, the most
important being the presence of a good substrate (in this case a food item); an
infection with viable bacteria; a temperature that allows bacterial growth; proper
pH; and sufficient water for bacterial growth. To guard against bacterial growth,
at least one of these conditions should he prevented.
Food irradiation is one method of improving the keeping properties of cer-
tain high-value perishable foods, thereby facilitating international trade. It con-
sists of exposing food to gamma rays, X-ravs, or electrons over a limited period
of time, which kill the present pathogens. Irradiation is the most recent addition
to the various types of food preservation that also include pasteurization, blanch-
ing, canning, freezing, and dehydration. It is recognized as a sale method of pre-
serving food and one that can contribute to the promotion of safe food supplies
as long as lhe occupational radiation hazard is prcperly controlled (WHO, 1988).
The advantages of irradiation over conventional food processing methods are that

(a) foods can be treated after packaging; (h) fresh foods such as meat, fish, fruit,
and vegetables that would otherwise be frozen or canned can be kept in the fresh
state; (c) perishable foods can last longer without loss of quality; and (d) the cost
and energy requirements of the process are lower than those of many conven-
tional methods (WHO, 1988).
Handling food may result in changes in its original composition. It is well
known that a relationship exists between certain processing techniques and the
quality and safety of the products. For instance, the heating of lipids and expo-
sure to oxygen are known to result in the formation of highly reactive oxidation
prcducts. Polyunsaturated fatty acids (such as linoleic acid) are especially sus-
ceptible to thermal and oxidative decomposition (rancidity). Another example of
the formation of toxic compounds during food processing is the Maillara' reaction,
a well-known but complex browning reaction of sugars and amino acids. Ani-
mal studies have indicated that these reaction products may induce liver dam-
age and disturb growth as well as reproduction. Furthermore, specific Maillard
reaction products may result in allergic reactions. The formation of Maillard re-
action products can be inhibited during food processing through regulation of
the pH, temperature, and water content. Polycyclic aromatic hydrocarbons (PAH)
are pyrolysis products that occur in food heated at temperatures over 300°C.
Benzo[ajpyrene, the most potent PAH carcinogen, has been found in the charred
crusts of biscuits and bread, barbecued meat, broiled mackerel, and other broiled,
baked, or roasted foods. Heterocyclic amines represent yet another group of car-
cinogens formed during preparation of meat and fish at high temperatures
(>150°C). Exposure to these compounds is found to be particularly associated
with colon cancer risk.
Food Preparation in the Home

The household is perhaps the most relevant place for developing strategies to
combat foodborne illness, as it is the location where the consumers can exert the
most control over what they eat. Clearly, one of the most significant components
of keeping food pathogen-free in the household is maintaining a clean and hy -
gienic environment in the kitchen or other food preparation areas. Proper sani-
tation facilities, cleanliness of household members who prepare the food, and
control of pests are all essential for the preservation of acceptable food. Many
bacterial pathogens are able to multiply in food because of the temperature at
which the food is stored. Figure 7.6 shows the temperatures at which bacteria
can be killed or controlled.
Refrigeration is one of the most effective means of stopping bacteria from
multiplying on or in food. Although bacteria are not killed, their growth is
stopped; they will start to multiply when the food is taken out of the refrigera-
tor into a warmer environment. Refrigeration does not change the nature of the
food itself, and food kept in the refrigerator will only remain in good condition
for a limited time. Most foodborne pathogens stop multiplying at temperatures
below 5°C. Therefore, for normal short-term storage of food, temperatures should
be kept below this temperature. Freezing food does not kill most microorgan-
isms. When frozen food is thawed, bacteria that were already there will begin to
multiply again unless the food is immediately cooked or held below 5°C.

.1c
100
Bacteria die if heated

for long enough.
Death rate increases
with time.
60
62.8
-- 1
Danger
zone
40.0
37.7
37.0
- -- / Bacteria
4multiply
rapidly
Bacteria
'multiply
P.
Bacteria
multiply
36.1 0000 slowly
15.0 --
-p'
---J
10
7.2—.
Most bacteria cease
0 to multiply but
donotdie
Figure 7.6 The control of path-

ogenic bacteria by temperature.
From Jacob, 1989, with per-
mission.
Fresh food, cooked and eaten while still hot, will not cause foodborne inlec-
tiOfl. Even though many raw foods are contaminated with pathogenic bacteria
when they are purchased, thorough cooking should kill the bacteria. If the cook-
ing is not thorough enough, bacteria can incubate within the food and produce
foodborne infections. Some bacteria give rise to SOCS that can survive cooking
and will develop into bacterial growth if the food is cooled too slowly or if it is
stored at kitchen temperature for too long.
The chemical risks in food preparation at home are the same as those present
during food processing. The general public should be made aware of these risks,
such as frying at high temperatures (grill or barbecue), which results in toxic re-
action products. Consumers should be advised not to use utensils that may con-
tain toxic materials, e.g., lead -glazed containers.
Food Preparation in the Food Services Industry

The consequences of improper food preparation in food services such as canleens
and restaurants can be much greater than that in the household, simply because
a larger number of individuals may be simultaneously exposed to unsafe food
items. It is essential to have a quality control program that will ensure the main-
tenance of food product standards during all stages of handling, processing, and
preparation; it must also be applied to all areas and equipment that come into
contact with food and beverages. Management of small or medium-sized estab-
lishmcnts is not always in favor of the implementation of such programs, find-
ing them to be too time consuming and expensive or too conlplicatcd. As a re-

BflX 7.7
Safety of Street-Vended Foods
Strcel foods can he defined as ready-to-ear foods and beverages prepared and/or sold
by vendors outside and in other public places (WHO, 1992c). Such street foods are
an affordable source of nourishment for people on low incomes and in many coun-
tries these people would be worse off if these foods were not available. The street
food industry has undergone remarkable expansirn particularly in Asian, African,
and South American countries. Although this industry employs 6%-25% of the
workforce, authorities remain hesitant to recognize it as a formal sector of the food
industry. As a consequence, this route of food supply may be ignored in food con-
trol programs and specific regulatory structures remain to be developed. Health haz-
ards related to street foods comprise all types of hazards discussed earlier in this
chapter. Cholera, hepatitis A, typhoid, and other diseases of microbiological origin
can be transmitted through such foods. In principle, foods that are thoroughly cooked
and consumed on the spot are safe, whereas precooked foods stored at ambient tem-
peratures of 5°-40°C for more than 4 hr present a considerable microbiological risk.
Hazardous chemicals and additives, notably unauthorized colorants and preser-
vatives, have been found in street-vended foods. Regulation of street-vended foods
should aim at ensuring safe, wholesome, reasonably priced food at convenient places,
without diminishing the economic, employment, and other benefits of this trade.
All extensive list of essential safety requirements for street foods has been estab-
lislied (WHO, 1992h), including recommendations regarding raw material and in-
gredients, place of preparation and sale, water, waste disposal, and preparation and
processing. Perhaps the most crucial point is the training of handlers, which has the
potential to be a more successful means of safeguarding food quality than punish-
ment of vendors, and should therefore receive more attention.
suit, the emphasis of quality control is often placed on the quality of the incoming
product, leaving a wide gap between the initial phase of quality control and ser-
vice to the consumer. Street foods arc particularly prone to lapses in safe food
preparation, as discussed in Box 7.7.
GLOBAL FOOD PRODUCTION CAPACITY AND FOOD SF.CIJRJTY
World Food Situation

Without adequate food and nutrition, there can be no sound social and/or eco-
nomic development in a community. Healthy nutritional status is best under-
stood as the complex interaction between our health, the food we eat, and our
surrounding environment. At the beginning of the 1990s, a worldwide average
of 2670 calories of food products per capita was consumed on a daily basis—a
level considered nutritionally adequate. However, this global average has little
meaning when inadequate food consumption levels are the norm in a significant
number of developing countries; there is a gap of 965 calories per capita. be -

BOX 7.8
Malnutrition
While the worlds most profound nutritional emergency is visibly exhibited in only
I or 2% of the world's children, an estimated 190 million children under age five
are chronically malnourished. The causes of malnutrition are complex—many
households run short of food between harvests, or amid drought and war. Many
malnourished children, however, live in homes with adequate food supplies and
need only a very small proportion of a family's intake to remain adequately fed. of-
ten low birth weight and specific practices such as bottle feeding contribute to mal-
nutrition in these cases. However, the main cause is the pattern of disease, espe-
cially diarrhoea, that thrives in poor communities lacking proper water and
sanitation (see Chapter 6).
When nourishment runs low, the body makes concessions to keep itself going.
These compromises may be invisible—the only outward sign is lethargy, as the body
attempts to conserve energy. To compensate for fewer nutrients, the body's ineta-
bolic rate drops, as does blood pressure. If body fat is low, it borrows from its re-
serves, thereby depleting niuscle instead of fat and damaging bone growth. Malnu-
trition amplifies all other illnesses and the risk of dying from some other disease is
doubled for mildly malnourished children and tripled for moderately malnourished
children. Good nutrition, by contrast, is excellent protection against disease.
Source: UNICEF, 1994.
tween the developed and the developing countries (3399 and 2434 calories per
capita, respectively). There are also wide gaps between and within developing
countries (UNEP, 1992a). Some people have too much food and suffer from an
unbalanced diet, whereas other people do not have enough to eat and suffer
from malnutrition. For a large part of the world's population, malnutrition re-
mains the major cause of mortality and morbidity (Box 7.8) and significant per-
centages of the world's populations remain undernourished (Table 73).
Crucial Conditions for Food Production

Considering the large number of undernourished and/or malnourished individu-
als in the world, it is hard to believe that there is enough food being produced to
meet the world's needs. Nonetheless, according to a report by the WHO's Panel
on Food and Agriculture, that is the case. Globally, food grain production has been
rising faster than the rate of population growth, and current and emerging food
production and preservation capabilities have the potential to produce an ade-
quate supply of safe, nutritious food for all the people of the world, both now and
up to the year 2010 at projected rates of population growth (WHO, 1992b). Much
of this production capability exists in developing countries where the greatest per-
centage of malnutrition occurs. In fact, the potential of many developing coun-
tries to increase their own food production through increases in yield, arabic land,
and cropping intensity is considerable. Together with the increased production of

TABLE 7.3
PREVALENCE OF CHRONIC UNDERNUTRITION IN DEVELOPING REGIONS
1969-71 1979-81 1988-90
Proportion Proportion Proportion
Millions of Total Millions of Total Millions of Total
of Under- Population of Under- Population of Under Population
Region nourished (%) nourished (%) nourished (%)
Alrica 101 35 128 33 168 33
Asia 751 40 645 28 528 19
Latin America 54 19 47 13 59 13
Middle East 35 22 24 12 31 12
Total
Developing
regions 941 36 844 26 786 20
Seventy-two countries with a population of less than 1 million, representing 06o of the developing world's
popala tion, were cxclttded from the table totals.
Sotirce WRL 1994,
food, storage facilities and distribution systems should be improved. Three ele-
ments must be in place for the production of food: land, water, and fertilizers.
The total area of potential arabic land in the world is about 3.2 billion hectares,
about 46% of which is already under cultivation. Although large areas of new
land could he brought under cultivation, unused arabic land is not always avail-
able to those who need it most, and opening up new areas is an expensive means
of increasing agricultural production. Soil that was once fertile is being degraded
through erosion, salinization, and pollution. In areas where fertile land exists,
water is often too scarce to properly irrigate it.
Worldwide, about 2700 cubic kilometers of water were withdrawn for irri-
gation in 1990, or about 70% of freshwater usc. As discussed in Chapter 6, fresh-
water resources are becoming more scarce, requiring increased wastewatcr reuse
and better maintenance of irrigation systems. In and and semi-arid zones, the
problem of water scarcity for food production is particularly acute.
The increased application of fertilizers to supply plant nutrients (nitrogen,
phosphorus, and potassium) is an essential component of modern agriculture.
Worldwide consumption of fertilizers has been increasing over the last two
decades (UNEP, 1992a).
Despite the appearance of global focd sufficiency, the global economic climate
has changed for the worse so that for some countries the corning years will bring
a deteriorating food situation. In every country, there are both rich and poor,
urban and rural, and industrialized and agrarian communities; even where na-
tional food supplies are adequate, large sections of the population may still not
have enough food for their needs. Over the next two decades, food production
will have to keep pace with an increasing world population. The challenge for
governments and food producers will be to ensure food and nutrition security
without placing undue pressure on the environment and perpetuating different
types of health problems (WHO, 1 992b). Estimates of possibilities for increased
food production are shown in Figure 7.7.

93 developing
countries
Sub-Saharan Africa
Eastern Mediterranean
North Africa
Figure 7.7 Possibilities of
increased food production. Asia
1982184-2000, I Yield in- (excluding China)
creases; 123 arabic land in-
Latin America
creases; fl increases in
cropping intensity. From
WHO, 1992b, with permis- 0 20 40 60 80 100
Si On. Increase (%)
Environment and Food Security

The continued supply of most staple foods and many other agricultural products
is dependent on the sustained productivity of a number of land-based ecosys-
tems. Some land-based ecosystems are of profound, though indirect, unportance
to the growing of food and agricultural production; they protect water basins
from floods and erosion, provide hiodiversity or habitats for natural enemies of
pests, and regulate the microclimate.
In addition to land-based agriculture, fish farming is a large and important
industry. The fishing industry contributes substantially to global food production
and provides many PeoPle with jobs and financial income. Of course, the qual-
ity of fishing waters relates directly to the quality of fish and other seafood. The
stability of maritime and other aquatic ecosystems is thus of crucial importance
to ensure continued food supply from this source. Overfishing is the most seri-
ous threat to aquatic ecosystems. Therefore, actions to protect the water quality
as well as regulation of fishing intensity are required.
Unfortunately, increasing numbers of productive ecosystems are being de-
graded and eventually lost due to human-induced environmental stress (WHO,
1992b; Box 7.9). Land degradation is a major environmental threat to food se-
curity. The depletion of the ozone layer and the changes occurring in the global
climate also pose a threat to the sustainahility of ecosystems. Intensive use of fos-
sil fuels is regarded as the major source of greenhouse gases. Any changes in the
climate as a result of the greenhouse effect, including temperature and humid-
ity, can have devastating effects on ecosystems and on the well-being and liveli-
hoods of people, particularly those dependent on natural systems. Similarly, the
depletion of stratospheric ozone, which absorbs much of the sun's ultraviolet
rays, can be particularly damaging to phytoplancton and may also affect crops
(WRI, 1994).
Global Trends
The most important factors that influence consumption and demand for food and
agricultural products are population growth, income distribution, and increased
urbanization. Most of the changes in consumption of food and agricultural prod-
ucts are due to growth in population and incomes. At constant per-capita in-

BOX 7.9
Environmental Stresses Leading to Land Degradation
DEFORESTATION
Forests are of particular importance to agriculture because of their protective func-

tions, especially in the tropics. As a result of the increased demand for agricultural
land and accelerated timber extraction, it has been estimated that approximately
100 million hectares of forest have been lost worldwide since 1950. Deforestation
is either large-scale, industrial, and immediately devastating to the environment or
is small-scale and insidious, leading to slow but steady degradation and impover-
ishment. The major effect of delorestation on agriculture is that the release of rain-
water becomes more erratic and, accordingly, threatens irrigation water supplies.
Massive deforestation is widely accepted to be responsible for excessive flooding in
fertile coast plains.
DESERTIFICATION
About one-third of the planet's land surface is either semi-arid or arid. Because of
the stress from drought, these areas have very low productivity. With prudent irri-
gation, productivity in these areas can be increased; however, these lands tend to
be very vulnerable to further degradation. The loss of vegetation can occur because
of natural climatic shifts. It may also be induced by human activities, such as tree
felling, inappropriate agricultural practices, or overgrazing by goats or cattle.
EROSION
Wind and water erosion strip away nutrient-rich topsoil, leaving the land less pro-
ductive. Erosion is nearly always caused by a decrease in the vegetative cover of the
soil by deforestation, overgrazing, and/or agricultural practices. Loss of topsoil
through water erosion is the most common form of soil degradation; however, wind
erosion is widespread in semi-arid climates.
Source. WHO, 19921,.
comes, the demand for loud and agricultural products was expected to increase
at about 1.7% annually during the 1990s. The greater part of this increase was
to occur in developing countries, with sub-Saharan Africa showing the largest
percentage increase (WHO, 1992h).
Only in recent decades have research findings confirmed the suspicion that
dietary preferences may influence the onset of many diseases, particularly those
attributed to the so-called affluent diet, a diet consisting of large quantifies of
high-fat and high-sugar foods. Examples of these diseases include obesity, heart
disease, and certain types of cancer. With about two-thirds of all energy coming
from vegetable sources and one-third from foods of animal origin, the developed
market economies have reached a level at which no further substitution between
the two groups is desired.

While low-income countries have traditionally relied on food from vegetable
sources, more animal products are now being consumed. Accordingly, the inci-
dence rates of heart disease, high blood pressure, and cancers are increasing
rapidly in some urban communities of developing countries. The relationship be-
tween income and meat consumption is reflected in the differences in meat con-
sumption—not only between developed and developing countries but among de-
veloping countries at different income levels. Rapid urbanization in developing
countries will also result in changes in patterns of consumption. A move from
traditional crops such as root crops, maize, and millet to food requiring less prepa-
ration time such as wheat, rice, and animal products is already taking place in a
number of these countries. As the demand for livestock increases, pressure on
agricultural land will become more intense. In addition to having direct envi-
ronmental effects, intensification of production will increasingly he based on cul-
tivating cereals for animal products that will compete for agricultural resources.
The conversion of cereals to animal products will result in large ]osscs of edible
energy and increases in resource requirements (WHO, 1992b).
ENVIRONMENTAL AND OCCUPATIONAL HEALTH

HAZARDS IN AGRICULTURE
Physical Injuries and Infections

Injuries are the most significant group of hazards for primary food producers. For
farmers, most major injuries are caused by machinery or farm vehicles. Un-
guarded equipment can injure limbs and eyes and can often take lives. Domes-
ticated animals and poisonous insects and snakes can all be a source of injury.
The level of noise produced by agricultural machinery—generators, tractors,
and saws—may be loud enough to cause hearing impairments in those workers
who are exposed to this noise over a considerable period of time. Vibrating tools
and machinery can cause fatigue, impaired balance, and chest pain, as well as
chronic health effects such as back pain and degenerative changes in the spinal
column and joints. These injuries may be exacerbated by the lifting of heavy ob-
jects. Children living in an environment (on or off the farm) with heavy ma-
chinery and many chemicals arc also at increased risk for injuries.
In addition to the risk of getting injured, the handling of large animals is as-
sociated with an increased risk of infection with zoonoses (see Chapter 2). Hun-
dreds of pathogenic organisms have been identified in association with animal
contact and a relationship has been established between the occurrence of a num-
ber of diseases and the intensity of the contact with animals. Farming in both
naturally wet and irrigated areas is also associated with an increased risk of
vector-borne infections (see Chapter 6).
Other occupations in the agricultural sector, such as hunting, fishing, and
forestry, have their own characteristic risk profiles. Hunters may be attacked by
wild animals or get injured by their own knives and firearms. For forestry work-
ers the main risks involve falling trees, saws, and ropes. Seamen are mostly ex-
posed to physical hazards related to machinery and moving objects; they arc also
at risk of falling overboard.

Production and Use of Pesticides
Pests and diseases have always been a problem in the cultivation certain crops
in certain seasons. The factors that have increased output per unit of land—in-
creased use of fertilizer, higher plant population, increased intensity, and new
plant varieties—have also increased disease and pest problems. The most com-
mon method used to control pests is the application of pesticides. Most pesticides
are chemicals used in agriculture to control pests, weeds, or plant disease (Table
7.4). A pesticide can he defined as
any substance or mixture of substances intended for preventing, destroying, or con-
trolling any pest, including vectors of human or animal disease, unwanted species
of plants or animals causing harm during, or otherwise interfering with, the pro-
duction, processing, storage, transport, or marketing of food, agricultural com-
modities, wood and wood products, or animal feedstuffs, or which may be admin-
istered to animals for the control of insects, arachnids, or other pests in their bodies
(WHO, 1990a).
The use of inorganic chemicals to control insects has a long history, possibly
dating back to classical Greece and Rome. In the middle of the nineteenth cen-
tury, modern pesticides began to be introduced. They replaced older plant-
derived pesticides, such as nicotine, and other chemical pesticides, including the
salts of arsenic. Many of the older compounds were highly toxic and their use
by the public was restricted in many countries. The introduction of dichloro-
diphenyl-trichioroethane (DDT), which was first synthesized in Switzerland dur-
ing World War II, seemed to be full of promise because of its wide spectrum of
activity and relatively low human toxicity. DDT is an organochlorine pesticide
that was followed by organophosphorus compounds and the carhamatcs. The
benefits of their use for agriculture seemed remarkable, as both the quantity and
quality of crops rose as a result of their use. Eventually, the health and envi-
ronmental pesticides to the agricultural workers became a major concern (see
Boxes 7.10 and 7.11). A wide range of insecticides, fungicides, molluscicides, hac-
TABLE 7.4
GENERAL CATEGORIES OF PESTICIDES
Pesticide Used Against Category Examples
insecticides Insects and related organophosphorons Malathion, parathion,
species COiiipoti nds dichlorvos
Carbaniate compounds Aldicarp, carbaryl, metliotnyl
Organochlorine compounds Aldrin, dieldrin, endrin, DDT
Pvrethroid compounds Bioallethnn, cvhalothrin
Rodenticides Rats, mice, and Ant icoagulants Wariarin and derivati es
other rodents Others Zinc phosj)liide, thallium
Herbicides Weeds Dipyridyl derivatives Paraquat, diquat
Phenol derivatives Pentachlorophenol
Fungicides Fungi and molds Dithioca rbamates Arasan, thirantid
Phta lami des Captan
Motluscicides Snails M eta Ide hyde
Fumigants Gases used to Ethylene (libr()nmmde
sterilize products Methyl bromide

BOX 7.10
DDT (dichiorodiphenyl-trichioroethane)
DDT, an organochiorine pesticide, was used widely from the 1940s to the 1960s.
DDT persists in plants and soil, passes along the food chain, and can thus be pres-
ent in food for human consumption. In the 1970s, these dangers were recognized
and the use of DDT was restricted in many countries. It is still, however, one of the
major pesticides in India and is widely used in developing countries to kill mosqui-
toes and thereby combat malaria. Like other organochiorine pesticides. DDT accu-
mulates in fatty tissue and is therefore found in food with a high fat content, par-
ticularly milk and dairy products.
Acute exposure to DDT (or other organochlorine pesticides) causes central ner-
vous system excitation (irritability, excitability, headache, disorientation, twitching).
High doses can damage the liver and are suspected to be carcinogenic and may in-
duce xenooestrogenic effects. Apart from its use to increase quality and quantity of
crops, DDT has also been widely used to combat malaria. After several years of suc-
cess in fighting this disease, resulting in significant benefits for human health, the
mosquito carrying the malaria developed resistance to the chemical.
Source.' UNEP/GEMS. 1992.
tericides, and herbicides, including lurnigants, have since become important in

agriculture. Without the use of synthetic pesticides the world food situation would
have been far more problematic than it is today. Furthermore, pesticide use has
contributed significantly to improved human health by reducing vector-borne
diseases. After several years of use, however, target pest species began to develop
resistance to the most widely used pesticides. Therefore, new compounds with
higher acute toxicity to humans had to be introduced, which resulted in unex-
pected effects on the environment. Since the use of pesticides has become so
widespread, and since the general public now has access to such a range of pow-
erful and hazardous chemicals, appropriate control of pesticides is needed. Al-
though many countries have introduced strict regulations and training in the safe
and effective use of pesticides, such precautions are not universal.
Populations at Risk for Exposure to Pesticides

The use of pesticides and the incidence of side effects vary considerably among
regions and farming systems. The use of pesticides in agriculture in developing
countries is very much connected to the type of market for which the farm pro-
duces. The very large, monocultural plantation farms are the most likely to use
pesticides. Exposure of employees to pesticides will vary according to the i'nan-
agement of the plantation. Farms with cash crops arc often family run and gen-
erally use smaller quantities of pesticides than plantations because of either in-
accessibility or prohibitive cost. Subsistence farmers usually do not use pesticides
at all because they cannot affcrd them and thus suffer the consequences of crop
losses.

BOX 7 11
Organophosphate and Carbamate
Cholinesterase-Inhibjting Insectides
These substances are the most common cause of acute pesticide intoxication. The
organophosphares (e.g., parathion, dichiorvos, malathion) and the carbamares (e.g.,
aldicarb, carbofuron, carbaryl) share a common mechanism of toxicity—cholinesrerase
inhibition. The nerve transmitter, acetyicholine, is normally itiactivated by an en-
zyme called acetvlcholinesterase. The action of this enzyme is blocked through the for-
mation of a pesticide–enzyme complex. The clinical presentation following acute
poisoning is easily recognized: neuromuscular paralysis, central nervous system dys-
function, and depression of red cell and plasma cholinesterase activity. The charac-
ter, degree, and duration of the illness depend on the degree and rate of accumu-
lation of aceryicholine. (Characteristic symptoms include blurred vision, tearing,
salivation, nausea, diarrhea, headache) Chronic effects may include dermatitis as
well as mood lability, fatigue, and impaired concentration. A delayed neuropathy,
rapid-onset distal symmetric sensory motor neuroparhy, may also occur.
In devek ping countries, approximately 63% of the workforce is employed in

the agricultural sector. In developed countries, the corresponding figure is 11%.
Thus, even if pesticide use in developing areas is low, relatively more people are
involved in the handling of pesticides. About 60% to 70 0% of all cases of unin-
tentional, acute pesticide poisoning are the result of occupational exposure. Pes-
ticide use in agriculture puts farmers and their families at risk for exposure. Work-
ers may he put at risk in other occupations as well, including pesticide
manufacturing, and as vendors, transporters, mixers, loaders, operators of appli-
cation equipment, growers and pickers, and rescue and clean-up workers. Chem-
ical burns of the eye, skin damage, neurological effects, and liver damage are
among the acute symptoms of occupational exposure. Chronic effects are more
difficult to identify, and there are varying degrees of evidence that different types
of pesticides are carcinogenic. For example, there is strong evidence that pesti-
cides containing arsenic arc associated with cancer in human subjects, whereas
the evidence for the carcinogenicity of organochlorinc pesticides is not strong.
Although only a small proportion of the general population is likely to receive
a pesticide dose high enough to cause acute severe effects, many more may be at
risk of developing chronic effects, depending on the type of pesticide to which they
have been exposed. Epidemiological studies of people who have been exposed to
low doses of pesticides are quite limited. The chronic effects suffered by these peo-
ple are often not specifically associated with pesticide exposure, and the exposure
levels arc often immeasurable. Individuals who receive very high levels of expo-
sure usually belong to well-defined groups, such as people using pesticides with in-
sufficient protective gear, people attempting to commit suicide, or people exposed
through the consumption of highly contaminated food or beverages (see Fig. 7.8).

Suicides and mass poisoning.
pesticide fomulators mixers ingl
applicators, and pick ers /and short-\
Pesticide manufacturers
/ /term, very high'\
level exposure
formulators, misers,
applicators, and pickers / Long-term
high level exposure
All population /
groups
Long-term, low level exposure

/
Figure 7.8 Population groups
at risk of exposure to pesti-
cides. From WHO, I 990a, with
permission. The width of the triangle indicates the approximate size of the esposed groups
The general population may be exposed to pesticides in several ways, the main
routes being ingestion via food and drinking water, inhalation via air and dust, and
skin absorption via clothing or direct contact. The most common cases of acute ac-
cidental poisoning by pesticides are those in which grain coated in pesticides has
been eaten. Other accidents have occurred when insecticides that are effective
against one type of pest were used incorrectly against other types, such as bedbugs
and lice. The use of old pesticide containers for household food and water storage
is another source of poisoning. Pesticides that are improperly stored have been con-
sumed by unknowing children. Studies of any link between pesticides and cancer
in the general population are difficult because generally the exposure levels are low.
Toxic Effects of Pesticides

Acute toxic effects are fairly easy to recognize, whereas the effects that result
from long-term, low-dose exposure are often more difficult to identify. Most pes-
ticide preparations include carrier substances, active ingredients, and compounds
that improve absorption. Many of these inert ingredients have severe side effects
that are often worse than those of the active ingredients. For example, carbon
tetrachioride and chloroform, both strong agents that are toxic to the liver and
central nervous system, may be used as inert ingredients without ever being men-
tioned on the product label. For most pesticides, a dose—effect relationship has
been defined in which the early effects of pesticides may be detected by mea-
suring minor biochemical changes before adverse health effects occur.
The severity of any health effects from exposure to pesticides depends on the
dose, the route of exposure, the type of pesticide, the absorption of the pesticide,
and the health of the affected individual. Pesticide uptake occurs mainly through
the skin and eyes. Individuals in developing countries, are particularly prone to
exposure through skin absorption, as protective clothing is often not worn. The
vapors of pesticides may be inhaled, and pesticides may be ingested through the
consumption of contaminated food. Within the body, the pesticide may be mc-
tabolized, stored in the fat, or excreted unchanged. DDT and hcxachlorocyclo-
hexane (HCH) are examples of organochlorine compounds that are not readily
metabolized and end up stored in fatty tissue.

TART F 75
TYPES OF TOXIC EFFECTS OF PESTICIDES
Biochemical Changes Reproductive Effects Skin Effects Neurological Effects
Enzyme induction Sterility irrita ut-contact Behavioral changes
dermatitis
Fetal death Permanent hair loss Lesions of the central
nervous system
Fetal toxicity Allergic- colt tact Peripheral neuritis
dermatitis
Teratogenicity Photoallcrgic reactions Peripheral neuritis
(fetal malformations) C It I ora cne
Deep scarring, skin
atrophy
In addition to the toxic elfects listed in Table 7.5, effects on human repro-
duction have been shown for a number of pesticides, including sterility, fetal
death, fetal toxicity, and teratogenicity (fetal malformations). Other recognized
effects of certain pesticides include cataract formation, cellular proliferation in
the lungs, and damage to the immune system.
Integrated Pest Manaqement
Pest management may consist of many different methods ranging from routine
applications of pesticides to measures for ecological management. Pest control
based solely on the application of pesticides is now increasingly rejected in most
countries. Instead, many approaches that can control pests while reducing pes-
ticide use are employed. In a pest management system, all suitable techniques
and methods are used in as compatible a manner as possible, and the pest pop-
ulation is maintained at levels below those causing economic losses (WHO,
1990a). Approaches that minimize pesticide use include plant disease forecasting
methods to minimize use; better formulation and placement of chemicals so that
smaller amounts are used; alternative farming systems to minimize pest attacks;
and repeated field visits to determine whether pest levels necessitate spraying.
A number of other pest control strategies are also increasing in significance,
including the use of biological insecticides based on insect pathogens; the release
or encouragement of predators of pests; release of sterile male insects to limit the
reproducticn of pests; planting of crop varieties that are resistant to pests; and
planting of trap crops to lure pests away from the principal crop (WRI, 1992).
Furthermore, modern biotechnological techniques offer the possibility to trans-
fer genes from one species to another, making crops more resistant to plagues.
For instance, it is well known that the bacterium Bacillus thuringiensis priduces
a toxin that kills larvae and insects. Using DNA recombination techniques, the
gene coding for the bacterial toxin has been isolated and transferred to tobacco
plants, where it is expressed. When insects eat from such a transgenic plant, they
die rapidly. However, these techniques are not yet widely accepted by society
and there is considerable reluctance to accept genetic engineering because of fears
of unanticipated effects and cultural concerns about the ethics of manipulating
life.

Fertilizers
Although the per-hectare use of fertilizers is currently much higher in developed
countries, the rate of use in developing Countries has been rising rapidly. Most
fertilizers used are nitrogenous fertilizers, followed by phosphates and potash.
About 50% of the fertilizers used benefit the plants; the remainder is lost from
the soil system by leaching and runoff, often causing contamination of ground
and surface water. As a result, the local or regional ecosystem will be disturbed
and specific forms of life may disappear. This type of pollution is also quite com-
mon in areas where animal wastes are applied to agricultural land. The problem
has been particularly acute on crop-livestock operations where farmers spread
large quantities of nitrogen-rich animal manure and continue to apply synthetic
fertilizers at the same rate that would be required without manure (WRI, 1992).
In many developing countries fertilizer subsidies have led to inefficient applica-
tion with consequent economic losses and increased environmental damage on
and off the farm (UNEP, 1992a).
Extensive use of fertilizers may also result in increased levels of nitrate in
ground and drinking water. One of the health consequences of high intake of
nitrates is the formation of methaemoglohin, resulting in a decreased oxygen
transport capacity of the blood. Infants are at increased risk for this adverse ef-
fect, known as the blue baby syndrome. High nitrate intake may result in increased
formation of nitrosamines in the stomach. Nitrosamines have been shown to ex-
ert genotoxic effects.
Some alternative farming methods minimize the need for chemical fertilizers.
Legumes in a crop rotation—the successive planting of different crops in the same
area—can help to fix nitrogen to the soil and thus reduce the need for additional
nitrogenous fertilizers. Alfalfa, chickpeas, and various clovers are among the
nitrogen-fixing plants; under proper management, soybeans can also add nitro-
gen to the soil (WRI, 1992).
Modern Intensive Farming Methods

The mass housing of animals in modern intensified agriculture may lead to an
increased exposure to dusts, toxic gases, and zoonoses. For example, intensive
poultry rearing brings large numbers of animals into close contact with each
other, resulting in an increased likelihood of infection in the herd with pests such
as Salmonella mites. In addition, intensive pig rcaring in confined spaces leads
to the buildup of high concentrations of carbon monixide (CO), ammonia (NH 3 ),
and dust. Such farming methods require adequate disposal systems for slurry. In-
tensive pig rearing has also been shown to result in noise levels of up to 102
dB(A), a level at which hearing protection equipment is required in the work-
ing environment (see Chapter 2, Physical Hazards).
A number of infections, including bruccllosis, leptosp]rosis, and chlamydiosis,
are also encountered in intensive farming. Brucellosis, a chronic bacterial infec-
tion, is characterized by joint pains, depression, and mood changes. In some coun-
tries this disease is now virtually eliminated by testing and slaughter regulation
program. The zoonoses, leptospirosis, and chlamydiosis continue to pose a health
threat, thus further study and measures to prevent their spread are required. The

spirochaete associated with leptospirosis is transmitted by animal urine, particu-
larly that of rats. Various types of leptospirosis infections, which all differ in the
severity and type of symptoms, occur in farmers and farm workers. Sugar cane
harvesting is a particularly risky setting for leptospirosis. Some types of lep-
tospirosis may be spread to people in dairy farming through contact with cow
urine. Outbreaks of chiamydiosis have been related to poultry as well as to rear-
ing of sheep. Women are at increased risk for this infection because they often
help with lambing. The placenta of the ewe may be heavily infected, which then
becomes an important source of human infection.
Apart from diseases related to cattle or livestock, farmers are at increased risk
for certain respiratory diseases. The inhalable substances to which farmers are
exposed include organic antigens such as pollen, fungal spores, animal allergens,
grain dust and mites, as well as chemicals such as nitrous oxide, hydrogen sul-
fide, methane, CO. and ammonia. Some respiratory diseases are associated with
silos. Three main types are recognized. Silo filler's disease is due to a toxic effect
of nitrogen dioxide and results in acute irritation and may cause pulmonary
edema, dyspnea (labored breathing), cough, and fatigue. Silo emptier's disease
(pulmonary mycotoxicosis) is a reaction caused by overwhelming concentrations
of fungal spores. Symptoms include upper respiratory irritation, dyspnea, malaise,
and fever. Farmer's lung disease and allergic alvcolitis may occur after exposure
to moldy grain silos, barns, and stocks.
Prevention and Control

In addition to integrated pest management, there are a number of techniques
that can reduce accidents and chemical exposure, including adherence to good
agricultural practices such as crop rotation, avoidance of excessive fertilizer ap-
plication, the use of proper dosages for pest control, and the correct use of agri-
cultural tools and machinery. Personal protective devices can also help prevent
accidents and chemical exposure. These include protective clothing and goggles,
respirators in dusty atmospheres, gloves, steel-toed boots, and hearing protec-
tion. Medical precautions include vaccinations of both humans and animals
against diseases such as tetanus, yellow fever, and rabies. Illnesses should be
treated early, before they become established in the individual or are transmit-
ted to others. Finally, the education of workers and others who are particularly
vulnerable to agriculture hazards (families of workers, for example) is needed on
an ongoing basis (WHO, 1992b)
Study ,ectrnc
How can the HACCP concept he used to reduce the formation of Maillard
reaction products?
Many different actions can be taken to improve the safety and quality of
our food. Prepare a summary of these actions, indicating (a) the level at which
this action should be taken and (Li) the type of contaminant (biological or chem-
ical) involved.

HUMAN SETTLEMENT AND
URBANIZATI ON
LEARNING_OBJECTIVES

• describe human settlements as ecosystems and name the basic require-
ments for their optimal functioning
• discuss the principles governing healthy housing
• discuss the health problems related to urbanization
• describe the principles of "healthy city" planning, and understand how
strategies are developed and implemented.
• indicate the factors leading to urbanization
• summarize health hazards characteristic of the urban environment
CHAPTER CONTENTS
The Nature and Requirements of Development and Ownership of
Human Settlements Land
Human Settlements as Ecosystems Conservative/Traditional Values
Basic Health Requirements of Mixed Implications of
Settlements Environmental Protection
Housing and Health Urbanization and Health
Housing, Communicable Diseases, The Urban Poor
and Infections Infrastructural Requirements of
Home Accidents and Toxic Urbanization
Exposures Air Pollution
Psychosocial Problems Noise
Factors Causing Increased Urbanization Motor Vehicle Accidents
Trends in Urbanization The "Healthy Cities" Approach
Migration to Urban Centers to Prevention
Rural Economic and Social Promoting Urban Health
Development Characteristics of a Healthy Cities
Differences of Time and Space Program
Dependence on Primary Industries From Program to Movement
Healthy City Actions
281
THE NATURE AND RFOIJIRFMFNTS OF HUMAN SFTTTFMFNTS
Human Settlements as Ecosystems

Chapter 1 introduced the concept of ecosystems. Before we discuss the health
requirements of settlements, it will be useful to think about human settlements
as ecosystems. An urban ecosystem is an urban nexus of dynamic conditions among
inhabitants and activities within urban areas or regions (Guidotti, 1995). In a sta-
ble, sustainable urban ecosystem, one group of persons or activities does not de-
stroy or harm the natural or human-made environment that supports and en-
hances the living conditions of other groups or systems of plants, animals, or
humans within that locale. Box 8.1 outlines the complexities of urban ecosys-
tems.
Universal principles for sustainable urban ecosystems include the following:
Ensure adequate water supply. In order to be sustainable, each urban
ecosystem should use only its fair share of regional freshwater and should not
have a negative impact on other ecosystems, either upstream or downstream.
Maintain vegetation cover. It is important to maintain and enhance the
natural environment, including treed and watered areas. This involves provision
of shade and cooling for people, plants, and animals; protection of banks and
slopes from erosion; and protection of topsoil from natural forces such as wind,
rain, heavy snows, and other storms. For example, heavily treed hillsides and
embankments will dramatically reduce the effects of flood-producing storms and
rapid runoff.
Preserve quality soils. As far as possible, the best soils should be preserved
for agriculture uses and lesser soils should be used for urbanization, including
buildings and infrastructure. The best soils need to be preserved for both present
and future food supplies.
Ensure sustainable conditions for wildlife. Protect natural open space sys-
tems surrounding urban areas, including treed and watered areas, to support
wildlife habitat and environments for all creatures. These are also important sen-
tinels for future environmental well-being of both humans and other species.
Maintain regional food production potential. To ensure that urban ecosys-
tems can be self-sustaining with respect to at least certain aspects of their fresh
food needs, it is essential to maintain and enhance local food production poten-
tial within the region of each urban ecosystem.
Create an urban environment on a human scale. Adapt the transportation
system, land use patterns, architecture, and governance of cities so that they are
convenient and energy efficient, responsive to the needs of residents, attractive
to live in, and diverse in cultural and socioeconomic terms.
Basic Health Requirements of Settlements

Both rural and urban settlements must meet many requirements to provide ad-
equately for the needs of economic, physical, and psychological health. The fam-
ily dwelling not only serves as shelter but is usually the focus of people's emo-
tional life. Settlements furnish a larger dimension of shelter, including basic
communal services such as water supply, waste disposal, communications, roads

BOX 8.1
A Framework for Ecosystem Health
As humans have become more alienated from their natural environment, the
biofeedback mechanisms that throughout time have regulated human–ecosystem
interactions have become more obscured. To provide a comprehensive explanation
of the intimate relationship between humans and their surrounding life-supporting
environment, a holistic transdisciplinary "ecosystem health" approach must take into
account the circumstances of these rapidly expanding built environments.
Urban settlements, ecosystems created by and inhabited by humans, consist of
both the built and human-modified physical environment. Thus they include the
processes of social aggregation, migration, modernization and industrialization, and
the circumstances of urban hying. These human-created urban ecosystems exist within
a larger frame of reference—the bio-regionai and planetary "natural" ecosystems that
ultimately provide fundamental life support. The social and economic development
that has played a central role in improved population health historically is built upon
those natural ecosystems, their resources and the "free" eco-services they provide.
Human health, thus, cannot he maintained if ecosystem health is not sustained.
DIMENSIONS TO CONSIDER
The relationship between the built environment, the natural environment, and hu-
man health is closely intertwined. Analysts such as Trevor Hancock (Hancock, 2000)
have drawn attention to six distinct dimensions of urban ecosystem health:
Health status of the urban human population in terms of its physical and men-
tal well-being, including health equity, the distribution of health, and well-
being across the different segments of the community;
Social well-being within the urban community, including social, economic, and
cultural conditions, the effectiveness of the processes of governance (including
education, participation, and access to decision-making power), and social eq-
uity, the distribution of these and other determinants of health;
Quality of the built environment, including aspects of housing quality, trans-
portation, sewage and water supply, roads and public transport systems, parks
and recreation facilities, and other civic amenities;
Ambient environmental quality within the urban environment in terms of air,
water, soil and noise pollution;
Health of the biotic community, including aspects of habitat quality and genetic
and species diversity;
Impact of the urban ecosystem on the wider natural ecosystems of which it is a
part, as measured by environmental sustainability concepts such as the urban
"ecological footprint."
Adequacy of urban ecosystems can he assessed in relation to their capacity to

support a liveable, viable, and sustainable quality of human life. By liveable, built
environment components such as the quality of housing stock and basic physical
infrastructure, such as water and sewerage, roads and public transportation, etc.,
and maintenance of public safety should be considered. By viable, basic life support
parameters should he taken into account. By sustainable, the impact of the urban
ecosystem on its surroundings is called into question.
(c'ntinued)
HUMAN SEULEMENT AND URBANIZA11ON 283

c_)
OA
c_
-- -
zz C
E zz -
- )p--
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fl
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—),-
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(continued)
In the developed world, the long-term sustainability of current patterns of re-
source consumption has been repeatedly called into question and questions of eco-
toxicity (e.g., endocrine disruptors, persistent and cumulative exposures) have been
frequently raised. Nevertheless, improvements in environmental protection achieved
over the last quarter of the twentieth century have contributed to create generally
ljveable conditions, albeit with threats to viability and sustainability. However, in
the developing world, there are many indicators of distress—and the ability to pro-
vide liveable and viable conditions is tinder considerable strain. Frameworks devel-
oped to assist decision-makers understand the relationship of human-ecosystem in-
teractions are especially valuable in understanding dynamic relationships between
driving forces, pressures, states, exposures, and effects (DPSEEA) within this envi-
ronment. The figure in this box builds upon Hancock's urban ecosystem dimensions
(Hancock, 2000), utilizing the DPSEEA framework discussed elsewhere in this text.
It shows how each dimension ultimately impacts human health, albeit mediated by
different pathways and determinants.
One example of how this framework is being applied within an urban ecosys-
tem community is in Centro Habana, Cuba, in which an extensive series of health
interventions were implemented in an inner-city community to try to improve the
quality of life and ecosystem health. The interventions addressed areas that the com-
munity perceived as being of highest risk, including housing conditions, environ-
mental sanitation, lifestyle concerns, social environment issues and immediate
threats to health. The results to date indicate the strong capacity-building nature of
applying such approaches (Yassi ci al., 1999; Fernandez ci at., 2000). In fact, the
development of analytical indicators collahoratively with the community is itself a
principle that has received recognition as an element consistent with an ecosystem
analysis (Spiegel et al. 2001).
Contributed by Dr. Jer7y SpkqeL
and public transportation, and the production and distribution of consumer goods
like food and clothing. They also enable the provision of services such as educa-
tion, health, and law enforcement, as well as provide infrastructure and support
for cultural, religious, and recreational activities. Settlements also give assistance
to vulnerable groups, such as elderly people.
In effect, a symbiotic relationship exists between family dwellings and com-
munity settlements, in which the values of both enhance each other. The fam-
ily dwelling is not just a place in which to eat and sleep but is also where peo-
ple store their possessions, relax, study, procreate, nurture and educate their
children, and often die. It is usually the most important focus of a person's life.
Settlements provide an umbilical cord of support for families and individuals.
Shelter requirements are to a large degree dependent on climate. For exam-
ple, in extreme northern and southern latitudes, shelter from cold is of central
importance, while in hotter regions protection from heat is essential. In low-
lying coastal or tropical regions, hurricanes, monsoons, and tidal waves are seri-
ous problems for communities, while in some inland regions, sandsiorms, tor-
nadoes, and blizzards present different problems. In regions where seismic ac-
tivities are possible, volcanoes and earthquakes pose a potential threat to
communities. Each of these conditions has inspired different designs for both
dwellings and settlements with regard to ideal infrastructure and housing needs.
HUMAN SETTLEMENT AND URBANIZATION 285

Although some variation in infrastructure does exist among settlements, there
are several universal requirements. All people require access to a safe and per-
manent supply of water and food as well as to appropriate household energy for
cooking, heating, lighting, etc. All humans produce fecal waste and generate at
least some food and other waste that require management. Additionally, most
communities have several features in common that require management. For ex-
ample, most have some connection to industry and must provide protection from
pollutants, and most have motorized traffic, which creates pollution and injury
risks. When communities are unable to meet these requirements, the result is
often health problems for community residents.
If housing design and development are to be effective, they must be based on
appropriate community standards and have the means to enforce them. En-
forcement of standards is particularly difficult for poorer communities, those in
developing countries, and in informal communities sometimes known as shanty-
towns. These hastily improvised communities spring up along the margins of many
big cities, usually in areas not designated as residential neighborhoods, and they
suffer greatly from substandard housing construction and maintenance. They are
usually exposed to industry and are isolated from both basic services, such as wa-
ter supply, and more complex ones, such as cultural venues. Often these com-
munities often cannot turn to government for intervention and assistance either
because they are technically illegal or the residents are disenfranchised politically
in settlements that are barely tolerated. They must therefore rely on community
initiative to address issues of concern.
The quality of housing from a health perspective can he assessed using a num-
ber of indicators (Box 8.2) categorized according to the driving force-pressure-
exposure-effect-action (DPSEEA) framework (see Chapter 3).
BOX 8.2
Examples of Environmental Health Indicators
DRtVING FORCES
• Migration • Population growl

• Urbanization • Poverty
• Land use • Settlement plann
PRESSURES
• Lack of housing • Lack of safe water supply or adequate

sanitation facilities
• Lack of surface water drainage • Lack of adequate excreta and solid waste
disposal
• Overcrowding, lack of living space • Lack of personal, domestic, and environ-
mental hygiene
• Use of home as a workplace; • Use of biomass fuel, coal, and kerosene
lighting for cooking, and heating

(coitinued)
• Use of unsafe food preparation • Lack of lighting, ventilation, and insula-
facilities ti011
• Lack of structural safeguards • Lack of open spaces and greenery
• Safety, chemical and fire hazards • Inadequate siting, inadequate protection
from floods, landslides, industry, and
traffic
LOCAL HAZARDS
• Microbiological and chemical contamination of water supplies (recreational and

drinking water)
• Contamination of food supplies • Indoor air pollution
• Refuse and wastes • Standing water (vector breeding sites)
• Dampness, odors • Pests, rodents, vermin, pathogenic organ-
isms
Fires, explosions
EXPOSURES
• Proportion of households to people with inadequate water supplies, sanitation fa-

cilities, and refuse removal services
• Proportion of households to people using coal, kerosene, or biomass fuels for heat-
ing, cooking, and lighting
• Proportion of households to people exposed to varying levels of indoor air pollu-
tion from indoor fires and environmental tobacco smoke -
• Proportion of households with high levels of radon, leaded paint, lead water pipes,
asbestos
• Proportion of households to people exposed to dampness, odors, or high levels of
noise
• Proportion of households to people exposed to pests, rodents, and vermin
• Proportion of households to people exposed to shelter that is strticturally unsafe
or sited on unsafe land, in close proximity to pollution-producing industry
• Proportion of people living in overcrowded conditions, with poor domestic and
environmental hygiene
• Proportion of households to people exposed to inadequate ventilation, lighting,
and insulation
EFFECTS
• Skin conditions (eczema, dermatitis, lice)

• Violence, crime, abuse, drugs, alcoholism
• Prevalence/incidence of accidents, injuries, and burns in the home, or traffic ac-
cidents
• Gastrointestinal diseases, parasitic diseases, tuberculosis, measles, and other com-
municable diseases
• Lead poisoning, neurobehavioral disorders, and other chronic, ill health—related
conditions
• Psychological/mental health conditions (stress-related, anxiety, depression)
• Environment-related respiratory conditions
ACTIONS
• Land-use planning and zoning measures

• Conservation measures
• Improved stove programs
(continued)
HUMAN SETFLEMENT AND URBANIZATION 287

conhinu'd)
Land and housing tenure measures
• Housing legislation, standards, and enforcement measures aimed at incremental
improvements in living conditions
• Impact assessment procedures for housing schemes
• Low-cost housing provision, housing upgrading
• Social and economic improvement programs
• Intersectoral programs for housing and health
• Community participation and action program support
• Education measures and advocacy programs for housing and health
• Adult literacy and empowerment programs for women
• Surveillance and monitoring programs, health risk assessment programs
• Service provision measures (e.g., water and sanitation, electricity, preventive and
curative health services, community services, emergency services).
HOUSING ANT) HEALTH
Housing, Cor municabie Diseases, and Infections

Housing conditions play a crucial role in the control of many diseases, especially
in the transmission of communicable diseases; a number of these factors have
been discussed in detail in previous chapters (Table 8.1). The home can both pro-
tect from disease or facilitate disease. Of all the factors listed in Table 8.1, water
supply and sanitation facilities often appear to be the most important in deter -
mining a community's health. Efficient drainage of surface water helps to con-
trol communicable and vector-borne diseases and reduces safety hazards and
property damage. Lack of, or a breakdown in, drainage systems can result in
vector-breeding sites. Flooding can result in similar problems. Appropriate solid
waste disposal and storage can discourage insect and rodent vectors of disease
and reduce population exposure to urban conditions likely to cause problems.
Solid waste management is even more crucial when excreta are among the waste
products. Waste disposal problems tend to exist predominantly in urban settings,
where there are space constrictions, crowding, and greater consumption. The ur-
ban poor are especially at risk because of their dependency on scavenging for
their livelihood, placing them in direct contact with all types of waste materials.
Personal and domestic hygiene is crucial to the reduction of numerous in-
fections, including skin complaints such as sepsis, dermatitis, and eczema, or eye
TABLE 8.1
HOUSING FACTORS INFLUENCING HEALTH
Sale and adequate water supply
Sanitary disposal of human and animal excreta
Efficient drainage of surface water
Appropriate solid waste disposal and storage
Personal and domestic hygiene
Safe food preparation
Housing structure and maintenance

TABLE 8.2
FEATURES OF HOUSING DESIGN THAT HELP PREVENT DISEASES
Design Feature Diseases Combated or Prevented
STRONG ASSOCIATION
Adequate supply of waler Trachoma, skin infections, gastroenteric diseases
Sanitary disposal of excreta Gastroenteritis and intestinal parasites
Safe water supply Typhoid, cholera
Bathing and washing facilities Schistosomiasis, trachoma, gastroenteritis, skin diseases
Means of food production Malnutrition
Control of air pollutioii Acute and chronic respiratory diseases
FAIRLY STRONG ASSOCIATION
Ventilation of houses (especially Acute and chronic respiratory diseases

if indoor fires)
Control of house dust Asthma
Siting housing away from vector- Malaria, schistosomiasis, filariasis, trypanosomiasis
breeding areas
Control of open fires, away from Burns
kerosene or bottled gas
Finished floors Hookworm
Screening Malaria
SOME ASSOCIATION
Control of use of thatch material Chagas' disease

Rehabilitation of housing Psychological disorders
Control of heat inside shelter Heat stress
Adequate food storage Malnutrition
Refuse collection Chagas' disease, leishmaniasis
Source: Stephens Ct at., 1985
disease such as trachoma and conjunctivitis, or contagious diseases such as tu-

berculosis (TB) and meningitis. Good hygiene is impossible to maintain without
adequate water supply. Features of housing design and the diseases they may
help to overcome are listed in Table 8.2.
Communicable Diseases If there are not sufficient rooms in a house to allow
for separation of sick people from healthy inhabitants, contagious diseases are
more readily transmitted. Overcrowding is therefore an important factor in the
spread of a number of communicable diseases. Additionally, housing with no ad-
equate sunlight and ventilation facilitates the spread of disease by increasing avail-
able breeding sites of vectors. This is especially true for (TB, one of the more com-
mon killers globally. Tuberculosis is a contagious disease that flourishes in crowded,
unhygienic environments. It is caused by bacteria that produce lung lesions, which
eventually impair lung function sufficiently to cause death. Once in place in the
human body, the bacteria are very resilient to treatment with antibiotics, making
the cure of patients with TB difficult and expensive. Elimination of the spread of
the disease, however, may be as simple as placing the sick person in a space with
adequate ultraviolet (UV) light and ventilation. As TB makes its way into poor

urban environments, it has the potential to have disastrous effects on many in-
habitants in both the developed and developing world because of overcrowding.
Meningitis is a communicable disease that kills many people worldwide. Like
TB, it is spread by airborne transmission and is linked to overcrowding and poor-
quality housing. Meningitis can be caused by many different viruses and bacte-
ria when they are able to penetrate the blood-brain barrier, which is normally
impenetrable. There is no external cure for the viral form of the disease, mean-
ing that patients' chances of surviving depend on the state of their immune sys-
tems. The bacterial forms can be treated by antibiotics, but the disease is fatal
and may develop rapidly, and it requires rapid and extensive treatment that is
not always successful. Other diseases, such as influenza, may also be transmit-
ted more readily if housing is inadequate.
Poorly maintained, unhygienic buildings also provide excellent breeding
grounds for many insect vectors, particularly in tropical regions. For example,
Chagas' disease is caused by a parasite transmitted by the Vinchuca bug, which
lives in the dark cracks and crevices of poorly built and maintained homes in
certain parts of South America. Its bite leads to a specilic type of heart disease
that is usually fatal within 10 years for adults and in much less time in children.
The poor are especially vulnerable to inadequate housing conditions. Just as
they cannot afford adequate housing, they also are generally not able to afford
proper nutrition, education, and health services. They are also more likely to be
exposed to dust, pollution, noise, and the hazards of climatic extremes because
of the nature of their economy and often flimsy housing.
Home Accidents and Toxic Exposures

Housing should also protect its inhabitants against physical hazards and toxic ex-
posures; this depends on both the structure of the facility and the behavior of
the people using it. In the planning of housing, many factors must be taken into
consideration to protect residents against these hazards, including structural fea-
tures and furnishings. Poorly designed or inadequately built homes increase the
risk of accidents and injuries, particularly for children.
A variety of injuries can be due to poorly designed or maintained housing.
Makeshift buildings that collapse on top of their inhabitants in earthquakes, heavy
rains, storms, or mudslides are common in the poorest areas of many countries.
Even under "normal" conditions, makeshift buildings made of poor materials re-
sult in a high number of injuries in or around the home. In more affluent coun-
tries, elderly people and young children tend to suffer more severe injuries from
falls down stairs, particularly if proper safety precautions are not incorporated in
housing. Elderly people often stumble on thresholds, carpets, or other flooring
hazards, causing hip fractures, one of the more common and costly injuries among
elderly people. Other injuries related to unsafe housing include burns from con-
tact with unprotected fireplaces or stoves or from house fires when occupants
cannot escape in time. Fires in factories, hotels, and other buildings where large
groups of people congregate can have disastrous consequences if buildings are
not suitably designed, lack fire protection or fire-fighting equipment such as ex-
tinguishers or sprinklers, or have insufficient emergency exits and evacuation
planning.

In many communities, indoor air pollution presently poses a much greater
health risk than outdoor air pollution. Residents dependent on open fireplaces
or unventilated stoves in their homes are most vulnerable, and the resulting res-
piratory diseases in children are responsible for as many fatalities globally as di-
arrheal diseases (WHO, 1997). Biomass fuels are used extensively for domestic
purposes; in some settings the associated health risks are severe (see Chapters 5
and 9). Fossil fuels are also commonly burned domestically and poor combus-
tion technologies expose people to harmful emissions of carbon monoxide (CO),
nitric oxides (NO), dust (suspended particles), and volatile organic compounds
(VOCS). Lack of ventilation, proper stoves, and chimneys greatly compounds the
risks associated with both fuel types. Additionally, construction materials and fur-
nishings are often a source of indoor pollutants, releasing a wide variety of air -
borne contaminants (e.g., formaldehyde, asbestos). Cigarette smc king also con-
tribute to air pollution, and the effects of environmental tobacco smoke (ETS)
can be severe.
Pollutants from the environment surrounding dwellings can also become a
problem. In a number of countries the natural leakage of radon and radioactive
gas has caused high levels of exposure inside dwellings and thus an increased
risk of lung cancer. Air pollution builds up in urban areas from the concentra-
tion of population and industry. The heating of houses with wood or coal fires
is a major source of outdoor urban air pollution in some countries.
Lead-based paints are a source of lead poisoning, especially in children. Ag-
ing water pipes made of lead or which have lead soldering in them are still in
use in some parts of the world.
Cottage industries, where the home is used as a workplace, carry an associ-
ated risk of contaminant exposure. Home industries often involve the use of haz-
ardous materials and produce noise and/or waste contaminants (either solid or
airborne). These risks are compounded in an urban setting, where, in areas of
high-population density, accidents such as fires can affect an entire community.
In some industrialized countries, the problem of sick building syndrome
(SBS)—or building-related illness, as it is sometimes called—is common. The fact
that most people spend 80% to 90% of their time indoors underscores the im-
portance of dealing with this problem. When the oil crisis in the early 1970s sent
the price of energy skyrocketing, industrialized countries put a priority on mak-
ing new buildings as airtight as possible. It was soon noted that gases given off
by construction materials and other pollutants could become trapped inside these
airtight environments, resulting in a range of health problems among those liv-
ing or working inside. Throughout the next two decades, the incidence of com-
plaints regarding air quality in homes, schools, office buildings, and other work-
places increased dramatically. The term tight building syndrome was originally
coined to describe this phenomenon.
Often SBS-related complaints are general and nonspecific. Symptoms typical
of SBS are shown in Table 8.3. Causes of SBS include inadequate ventilation (Cs-
timated in the United States in the mid-1980s to be responsible for 50% of cases);
some source of environmental contamination, from either inside or outside the
building (30%); and unknown causes (10%). Building materials, humidity,
molds, cigarette smoke, noise, and illumination account for the rest (10%). In

TABIF Rl
TYPICAL HEALTH COMPLAINTS ASSOCIATED WITH SICK BUILDING SYNDROME
Nasal congestion and sinus problems
Headaches
Fatigue I drowsiness
Eye irritation
Respiratory difficulties (e.g., chest tightness, exacerbations of asthma, increased number of upper
respiratory tract infections)
Skin problems (e.g., eczema and other rashes)
addition, inadequate humidification can cause dry air (a known cause of irrita-
tion to eyes, skin, and throat), static electricity, and temperature fluctuations.
Sources of environmental contamination include ofi-gassing from new furni-
ture or carpeting, cleaning materials, chemicals from adjacent offices, unclean
ducts, fibreglass, and cigarette smoke. Virtually all dusts, vapors and aerosols that
can react with proteins can cause an allergic rcacticn. Generally considerable ex-
posure is required to become sensitized. However, once the individual has be-
come sensitized to any of these, allergic reactions may be elicited after only a
brief and low-concentration exposure.
Psychosocial Problems
Reducing psychosocial stress is a vital role of proper housing, as the link between
a good psychological environment at home and health is strong. Poor psycholog-
ical health makes pecple generally more susceptible to many ccmmunicable and
chronic diseases and there are numerous other health problems that accompany
poor psych( logical health (e.g., psychosomatic illnesses, substance abuse, mental
illness, and violent behaviors). Increasingly, housing in urban settings fails to serve
the role of psychosocial haven, as overcrowding and the stresses of urban life pro-
duce exactly the opposite effect. Urban housing, with its model of individual fam-
ily homes (transplanted from the developed world to communities all over the
globe), often tends to break down traditional community structures that existed in
rural environments, increasing individual alienation. The urban poor have the ad-
ditional burden of living in insecure tenant situations and being subject to ex-
ploitation in their housing environments. All of these problems arc experienced
most keenly by those making the transition from rural to urban life. The trend to-
ward urbanization makes this problem urgent. Many factors involved in housing
can reduce these problems to a minimum, some of which are listed in Table 8.4.
TABI.E 9.4
FACTORS AFFECTING CONTROL OF PSYCHOSOCIAL PROBLEMS
Living space should he sufliciently large and reasonably Irivate and comfortable.
The housing environment must he safe and couducive to community interaction.
Recreational space must he available to neighborhood residents.
Neighborhoods should be protected against traffic noise and industrial pollution.
Parks, l)laygrouflds, and other community amenities should he easily available.
Housing should he easy to maintain and keel) clean.

FACTORS CAUSING INCREASED URBANIZATION
Trends in Urbanization
Urbanization, the process by which an increasing proportion of the population
comes to live in urban areas, has become a worldwide problem. Urbanization is a
reflection of population growth and opportunities in cities. A population can grow,
only through increase in births, decrease in deaths (the natural increase); or in-
creased immigration. Decreased emigration may reduce the loss of population if
the rate of immigration does not also fall. Urban areas of the world are now ex-
periencing both a natural increase and an increase in net migration to the cities.
in 1999 the world's population reached 6000 million people—more than three
times the population of 100 years ago. A 30% rise is predicted by the year 2010.
Of this predicted growth, 90 0% is expected to occur in countries that are presently
classified as developing countries. Urbanization is also occurring at a dramatic
pace. The urban populations of developing countries will double in the 20 years
from 1990, which means that by 2010, well over half the world's population will
he in urban centers, or about 4000 million people UNEPIWHO, 1992c). By 2025
it is expected that more than 5000 million will live in urban areas, as shown in
Figure 8.1 (WRI, 1996). Urbanization has been growing in developing countries
at a much faster rate than in developed countries. It is estimated that by 2010,
60 1VO of the developing countries' urban population will be living in shanty towns
or informal settlements.
Of special concern in this global trend of urbanization is the growth of mega-
cities, or cities with a ptpulation of 8 million or more; it is projected that by 2015
there will he 36 megacities (UN, 1997). The largest cities are listed in Table 8.5.
Megacities warrant concern because their sheer size creates great challenges to
human health and the environment.
1101
(I)
0
6
.0
=
C
0
4
75
0
0
0
1950 1975 2000 2025

Year
Figure 8.1 Urban population growth. 1950-2025. From UNDP. 1995, with permission.
HUMAN SE1TLEMENT AND URBANIZATION 293

TABLE 8.5
THE WORLD'S LARGEST CITIES, 1995 AND PROJECTED 2015
Population Population
(millions) (millions)
1995 2015
Tokyo, Japan 26.9 28.9
Mumhai (formerly Bombay), India 15.1 26.2
Lagos, Nigeria 103 24.6
São Paulo, Brazil 16.5 203
Karachi, Pakistan 9.8 19.4
Mexico City, Mexico 16.6 19.1
Shanghai, China 13.6 17.9
New York, U.S.A. 163 17.6
Calcutta, India 11.9 17.3
Delhi, India 10.0 16.9
Beijing, China 11.3 15.6
Metro Manila, Philippines 9.3 14.7
Cairo, Egypt 9.7 14.4
Los Angeles, U.S.A. 12.4 14.2
.Jakarta, Indonesia 8.6 14.0
Buenos Aires, Argentina 11.8 13.9
Tianjin, China 9.4 13.5
Seoul, Republic of Korea 11.6 11.0
Rio de Janeiro, Brazil 10.2 11.9
Osaka, Japan 10.6 10.6
Paris, France 9.5 9.7
Dhaka, Bangladesh 7.8 9.5
Moscow, Russian Federation 9.3 9.3
Source: UN, 1996
Migration to Urban Centers

People migrate from rural to urban areas for a variety of reasons. As life ex-
pectancy increases and the birth rate rises, single farms may not be able to sup-
port all family members. In addition, rural customs and discriminatory inheri-
tance laws can encourage or force migration from rural areas. Improved survival
of children has created a rapid growth in the number of young people without
sufficient land to support them.
TABT.F. 9.6
FACTORS AFFECTING REGIONAL URBANIZATION
Changes in a region's economic or employment base often lead to increased employment opportu-
nities in urban centers.
Areas with unequal income distribution, where only a few individuals are affected by economic
growth, experience signiticantly diflerent urbanization patterns than areas where many people
have access to economic l)enefits.
Political structures can affect the distribution of poverty and hence urban developnient areas.
Government niacroecononlic policies may favor urban centers, and thus increase urbanization
rates.
World markets, which intlitence national economics, necessarily influence urban systems.

Economic and political factors greatly influence migration patterns (Table 8.6.)
Many developing countries, for example, Cote D'Ivoire, Indonesia, India, Mex-
ico, Brazil, and Thailand, are expanding their economies rapidly and along with
this expansion are experiencing very high rates of urbanization. An increased
economy means more industry. Jobs follow industries, and people often follow
jobs. People thus migrate to cities to seek work, better living standards, better
education, and other facilities and services. Population movements to the cities
have also been accentuated in many countries, e.g., in Somalia in the 1970s and
Ethiopia in the 1980s, as a result of famine, drought, and other natural hazards
in rural areas. Additionally, wars, natural disasters, and ecological crises can have
a large impact on urbanization trends of specific regions. By contrast, many coun-
tries with stagnating economies, falling public expenditures, and enormous debt
burdens have experienced much slower urban growth than predicted.
In developed countries, a shift away from urbanization to suhurbanization is
occurring as people and industries seek locations just outside major cities. These
cities may be beccming too expensive for people and industries. Advances in
transport and communications and changes in economic structures (e.g., away
from heavy industry and toward the service sector) enable rural areas and small
towns to attract enterprises and inhabitants that were previously located only in
cities. As more of this suburbanized population commutes to the city to work,
rural populations in developed countries tend to he less agriculturally based. It
should be emphasized, though, that the net shift in populations in developed
countries is toward urbanization (WHO, 1992c).
RURAL ECONOMIC AND SOCIAl DEVET 1)PMFNT
Differences of Time and Space

Rural communities undergoing development must deal with realities of time and
space that are different from those of urban communities. In rural areas, distances
between suppliers and consumers are greater, transportation takes longer, and the
density of population is much less than in a city, so there is less efficiency in con-
ducting business. Because the density is lower, and usually more evenly distributed
than in an urban area, it is often more practical to do business by bringing people
together at a particular time, rather than in a particular place. This is the basis of
the traditional marketplace, where people come on a particular day to buy and sell
goods and to conduct their personal business. Fairs, festivals, and expositions ac-
complish the same purpose. Many cities began as permanent settlements that grew
on the sites for such markets and fairs. (To get an idea of how common this was,
one need only look at a map of England. Most country towns and all cities ending
in "chester" started this way, as well as many others.) Prices for local commodities
and land (except in agriculturally rich areas) tend to he lower in rural areas than
in cities, but the cost of construction and transportation can he much higher.
Dependence on Primary industries

The economy of most rural areas is based on agriculture and resource industries
such as mining, forestry, and fishing. Agricultural commodities and fishing may

help to sustain a community, but most rural areas survive economically by sell-
ing these commodities or trading for the goods they need.
Because commodities produced in the rural area must be sold or traded, rural
areas tend to be susceptible to changes in prices. If the demand for their com-
modity drops, prices may fall abruptly, as has often been the case for crops such
as coffee or cacao. This means that rural areas are often highly dependent for
their prosperity on goods that have fluctuating prices, and this leads to economic
instability. Diversification of the rural economy has therefore been a goal in many
countries. Where the density permits, some limited manufacturing can be sup-
ported, as with township industries in China where the rural districts are much
more densely populated than in most countries. In developed economies, in-
dustries based on information services are now increasingly common in rural dis-
tricts because improved communications make it easier to live farther away from
customers.
The economy in rural areas tends to be seasonal. Crops are planted, tended
and harvested by the time of year and weather, and fishing may occur only dur-
ing certain times of the year. Many rural residents make their living by selling
crafts or working in industries such as mining during the off-season, and farm
or fish when they can. As a result, a farmer in a rural area may be accurately
described as someone who does many jobs, among them, farming.
Development and Ownership of Land

tn developing countries, rural areas are often less developed than cities. The in-
frastructure is often relatively poor because the investment is less productive in
less dense settlements and the area to be served is much greater. Rural poverty is
a common problem that is aggravated if the rural area is remote from industries
that could provide employment or if agriculture is weak or commodities unstable.
Land ownership, an important issue in agricultural communities, often lies at
one of two extremes: (1) widespread ownership of small plots of land that are
too small to be economically productive or (2) concentrated ownership of very
large areas of land in the hands of a few people or families. Concentrated own-
ership is often associated with social unrest, exploitative labor practices, and over-
reliance on cash crops that are dependent on commodity prices. In such soci-
eties, the tension between land owners and a class of resident farmers who work
the land and are required to pay rent is often the basis for social unrest.
Conservative/Traditional Values
Socially, rural areas tend to be conservative and traditional. Families, clans, and
neighbors are very important where there are few social institutions that can
guarantee security and when communities are small. This conservatism is not
absolute, and the influence of modern communications and transportation has
clearly reduced the isolation of many rural areas. Likewise, the need to pay at -
tention to commodity prices has made many rural residents experts on the op-
eration of international markets. Overall, however, rural areas tend to be places
where traditional values arc held for a long time and where change is resisted.
Consequently, more and more rural young people leave the area to try their luck
in the city.

Mixed Implications of Environmental Protection
Environmental protection has mixed meaning for rural areas. To the extent that
environmental protection preserves the advantages of rural life and makes life in
villages and isolated communities safer, it is welcomed. However, environmental
protection may be perceived as threatening to a community if it changes farming
practices, removes resources from economic use, or interferes with the construc-
tion or development of infrastructure. Villagers that make their money during a
certain season from, for example, wood cutting or catching fish may not accept
that it is necessary to preserve the forest, reduce the catch, or save the soil.
URBANIZATION AND HEALTH
The Urban Poor

Globally, urban residents enjoy better health than rural populations. This fact
does not take into account, however, the differences within cities between
wealthy and poor populations, which can be staggering. In many cities, poverty
among urban residents is widespread. In developing countries it can alfect the
majority of the residents, and in developed countries it is on the rise. Poverty is
a major factor in exacerbating the risks discussed earlier. The health situation of
the urban poor is often worse than that of people living in rural areas. The ur-
ban poor must endure the difficulties of rural life (lack of services, decreased ac-
cess to health care) along with many urban hazards (crowding, stress, and ex-
posure to industrial hazards). Figure 8.2 illustrates that a large proportion of
residents in the major cities of developing countries live in poverty. Thcse fig-
ures are from 1988; the situation is worse today.
The process of urbanization has often been haphazard and chaotic. Most of
the urban poor live in low-quality, overcrowded, self-made forms of shelter that
are only marginally served by the public utilities taken for granted by others. In
many cities, a majority of people live in shantytowns, or informal settlements,
which in turn account for more than half the built-up areas. Informal settlements
can account for up to 90% of low-income settlements, as they do in Addis Abaha
and Yaounde.
There arc two important points to note about these settlements. The first is
that they are not a temporary phenomenon brought about by a dysfunction in
the development process, but rather a product of low wages and the inability of
governments and agencies to provide adequate settlements. The second point is
that these settlements differ widely around the world with respect to culture, le-
gal status, tenure, levels of home improvement, age, physical structure, com-
munity involvement, immigrant status, and major health problems facing them.
They should not be treated as a homogenous population (UNEP/WHO, 1987a).
Nonetheless, there are certain infrastructural requirements and problems that ap-
ply to all such settlements.
Infrastructu ral Requirements of Urbanization
The process of urbanization has significant requirements, including the provision
of water safe for household consumption and sanitation purposes, solid and liq-

Addis Ababa
Casablanca
Kinshasa
Bogota
Calcutta
Buenos Aires
Mexico City
Bombay
Manila
Bangkok
0 20 40 60 80 100
Percentage
Figure 8.2 Percentage of people living in slums and squatter settlements in some urban
centers (1988). From UNEP, 1992a, with permission.
uid waste management, and housing and transportation networks. All of these
are energy-expensive but they must be met, at least to some degree, to ensure
a minimum standard of health. The rapid pace of urbanization in many areas has
virtually outstripped the ability of local governments to provide these services
adequately. Additionally, promotion of economic growth has led to industrial ex-
pansion that frequently overwhelms the existing urban services. Several of the
health-promoting housing design features listed in Tables 8.1 to 8.4 relate di-
rectly to urban infrastructure.
Air Pollution
As discussed in Chapter 5, air pollution is one of the many problems modern cities
experience, no matter what their level of economic development. In the past, air
pollution was often considered a matter of aesthetics and quality of life, but not
of survival or health. Increasing scientific evidence has shown that the effects of
air pollution on health are considerable, even in developed countries where the
levels of air pollution have been largely controlled. This has led to a reexamina-
tion of the need for air quality management. The negative effects of air pollution
are now taken much more seriously. The annual sulfur dioxide (SO 2 ) and sus-
pended particulate matter (SPM) levels in cities involved in the Global Environ-
mental Monitoring System (GEMS) are shown in Figures 8.3 and 8.4.
The principal sources of emissions into the air are the direct products of ceo-
nomic activity in cities: transportation, power production, home heating and
cooking, and industrial production. The costs imposed by air pollution are most

Concentration (,io / m 3 ) 10 100
Key
1 Milan Ran
2 Shenyang ItA
3 Tehran
4 Seoul
5 Rio de Janeiro
6 S8o Paulo
7 Xian
8 Paris
9 Beijing
10 Madrid
11 Manila
12 Guangzhou
13 Glasgow
14 Fankturt
15 Zagreb
16 Santiago
17 Brussels
18 Calcutta
19 London
20 New York City
21 Shanghai
22 Hong Kong
23 Dublin
24 St. Louis
25 Medellin
26 Montreal
27 New Delhi
28 Warsaw
29 Athens
30 Wroclaw
31 Tokyo
32 Caracas
33 Osaka
34 Hamilton
35 Amsterdam
36 Copenhagen
37 Bombay
38 Christchurch
39 Sydney
40 Lisbon
41 Helsinki
42 Munich
43 Kuala Lumpur
44 Houston
45 Chicago
46 Bangkok
47 Toronto
48 Vancouver
49 Bucharest
50 Tel Aviv
51 Call
52 Auckland
53 Melbourne
54 Craiova
WHO Guideline 40 - 60 pg m3
Figure 8.3 Annual SO 2 measures in GEMS/Air cities, 1980-84. From UNEP/WHO, 1987b,
with pern1ission.
obvious in cities as well: human health problems, destruction of materials, plant

and animal damage, poor visibility, loss of appeal for tourists, and reduced qua!-
ity of life for residents.
City and regional planning can make a great difference in determining air qual-
ity. The provision of energy-efficient mass transportation, for example, can greatly
reduce air pollution from motor vehicles. However, if the city is large and spread
out, mass transit may not be practical, and if it is too expensive, it may not be
used. The location of industry in or near residential communities or in valleys,
basins, or other landforms that collect pollution can aggravate the problem. Box
8.3 presents some major accomplishments in promoting the use of nonmotorized
vehicles that have occurred across the globe. Housing that is energy-efficient and
power supplies that are both energy-efficient and reliable may reduce the amount
of air pollution, but these require an investment in infrastructure.

10 100 1000
Key
1 Kuwait Range of individual site
2 Shenyang annual averages
3 Xian
4 New Delhi
5 Beijing I I I
6 Calcutta
7 Tehran f
Combined site
8 Jakarta
9 Shanghai average 1980-84
10 Guangzhou
11 Illigan City
12 Bangkok
13 Bombay
14 Kuala Lumpur
15 Zagreb
16 Rio de Janeiro
17 Bucharest
18 Acera
19 Lisbon
20 Manila
21 Chicago
22 Caracas
23 Birmingham
24 Helsinki
25 Hamilton
26 Sydney
27 Houston
28 Cralova
29 Toronto
30 Melbourne
31 Medellin
32 Chattanooga
33 Fairfield
34 Montreal
35 Vancouver
36 New York City
37 Tokyo
38 Osaka
39 Cali
40 Copenhagen
41 Frankfurt
WHO Guideline 60— 90g m3
Figure 8.4 Annual SPM measures in GEMS/Air cities, 1980-84. Front UNEP/ WHO, 1987h,
with permission.
In recent years, it has become obvious that pour comn)unities tend to he inore
affected by air pollution than those with higher average incomes. This observa-
tion has been followed by a number of studies that have shown that exposure
to pollution tends to accompany pcverty, marginalization from society, and lack
of access to social services and health care. The 1ikely explanation for this is that
people who have access to personal resources are more likely to live together,
a oiding unhealthy or unpleasant neighborhoods. However, there is also evi-
dence that factories, power plants, or other facilities that may be sources of poi-
lution are more likely to be built in or near poor communities in the first place.
The problem of equity in environmental risk, called environmental justice, is an is-
sue of serious concern in discussions and policies regarding air pollution, Con-
taminated water supplies, and hazardous waste disposal.
Noise
The major sources of noise arc road and air traffic, Construction, industry, and
people. These types of noises are generally on the rise as urban centers become
more dense, industry expands, and the need for transportation increases. Noise
is of most direct concern in the workplace, where hearing loss most commonly
occurs. (Industrial noise and its control are also discussed in Chapters 2, 4, and

B(TX 9.3
Examples of Success in the Use of Nonmotorized Vehicles
In many countries of the world, governments have actively promoted bicycle com-
muting. For example:
• In China, where 50%_80% of urban trips are by bicycle, the government offers
subsidies to those who bicycle to work. It has also allocated extensive urban street
space to bicycle traffic.
• Prompted by Cuba's petroleum crisis, car traffic has been reduced in Havana by
35% and bus traffic by SOC/u, and bicycle use has been actively encouraged. Now,
one of every three trips in Havana is made by bicycle. The city government re-
duced car speeds to improve safety conditions, and in addition to offering bicy-
clists subsidies, has constructed bike lanes.
• In developed countries, Denmark and The Netherlands have done a great deal to
promote bicycle use. The Dutch National Transportation Plan aims to increase the
amount of cycling by 30% by 2010, by providing new bicycle routes, parking at
railway stations and bus and tram stops, and additional safety measures, despite
the fact that bicycle use is already very high in this country.
• In several cities in Canada and Australia, extensive bicycle paths have been in-
troduced.
• In Seattle, all buses in the Metropolitan Transit System are now equipped with
bicycle racks.
These examples illustrate how, if properly promoted and encouraged, bicycles can
provide access to shopping, schools, and work. This can help reduce air pollution
and the other problems associated with motorized vehicles described in this chap-
ter. In addition, bicycle use is a form of active transport that gives much-needed
physical exercise to sedentary populations of developed countries.
Source: WRI, 1996.
10.> However, as rates of urbanization all over the globe exceed the ability of
city planners to protect residents from noise, increasingly it has become a gen-
eralized urban problem.
As discussed in Chapter 2, noise may cause physical, physiological, and psy-
chological effects in humans. The physical effect of sound waves against the ear
drum resulting in hearing loss is sometimes referred to as a direct effect. The phys-
iological changes that may register cognitively include sleep disturbance and psy-
chological damage, and are considered indirect effects. The dose—response rela-
tionship between noise and hearing loss was discussed in Chapter 2.
Environmental noise, (also called community noise) is often complex (Ry-
lander, 1992; Berglund ci al., 1999). Acoustical patterns are traditionally ex-
pressed as the summation of sound energy over a certain period of time. Vari-
ous methods of calculating an average have been developed, such as the noise
pollution level, the average day and night level, and the equivalent sound level

(Leq) for different parts of the day. (For a complete review of noise-related is-
sues, the reader is referred to the Guidelines for Community Noise produced by
the WHO [Berglund et al., 19991.) The concept of average level has two critical
features. A few events with a high noise level will have the same Leq as a large
number of events at a lower noise level. However, it is unlikely that these two
noise scenarios will cause an equal effect in the exposed populations. A second
critical feature for the average noise level relates to the number of events. If, for
example, the noise increases because of an increase in the number of cars, the
Leq will gradually rise, even though the noise level from each car is still 65 dB(A).
There is no strong documented evidence that environmental noise generally
or road traffic noise in particular can cause long-term hearing damage; levels in
the general environment do not reach those that will induce hearing damage,
even in areas close to traffic along heavily congested streets. This is important to
bear in mind when assessing exposure and estimating risk. The interaction of
noise from road traffic with other sounds in the environment is nonetheless im-
portant. Noise levels causing speech interference are often present in areas close
to heavy road-traffic and air-traffic. Vulnerable groups in the population include
school children in noisy classrooms who may experience performance, attention,
memorization and reading problems than children in quieter rooms (Berglund
et al., 1999).
As noted above, the immediate response to a noise stimulus often comprises
a startle and a defense reaction. The startle reflex may be accompanied by an in-
crease in blood pressure and pulse frequency of a very short duration (up to 30
sec), and in extreme situations, an increased secretion of stress hormones. A re-
view of the cardiovascular effects of noise reported that of 55 studies that as-
sessed the relationship between noise and blood pressure, about 809/o reported
some form of positive association (Dejoy, 1984). The author noted, however, that
there is a lack of quantitative data and it is difficult to assess strength of associ-
ation or to derive a dose—response relationship. In any case, it would be difficult
to distinguish the influence of noise from other environmental stress factors,
which could also iroduce a slight increase in blood pressure.
Exposure to noise can induce disturbance of sleep through causing difficulty
in falling asleep, alterations of sleep rhythm or depth, and being awakened. Ev-
idence suggests that sleep disturbance is one of the major adverse effects of en-
vironmental noise, and this may seriously impede normal functioning and health
in exposed populations. Noise can also give rise to headaches, fatigue, and irri-
tability. The exact conditions under which sensitive individuals become vulner-
able are not known, but it is conceivable that other environmental strains could
act synergistically with noise. A discussion of a dose—response relationship be-
tween the intensity of noise and the extent of nonspecific nuisance, disturbance
of night rest, disruption of conversations, and shock or startling reactions is pre-
sented in Box 8.4 and Table 8.7.
Annoyance with noise is widespread in urban centers and around airports.
According to the definition of health cited in Chapter 1, subjective annoyance
should be considered an important health effect, an adequate rationale for tak-
ing action against noise. A practical means of confronting the problem is to make
the subjective interpretation of noise the primary criterion. Noise standards could

BOX 8.4
Noise and Nuisance
Noise may affect health by inducing nuisance. Nuisance is a difficult concept to mea-
sure objectively and has many of the characteristics of psychosocial hazards dis-
cussed in Chapter 2. For instance, the extent to which a person is aggravated is not
merely determined by the type and intensity of the noise but also by personal char -
acteristics or circumstances. Nuisance may he rather specific—for instance, when a
conversation is interrupted by a passing train, but it can also be nonspecific and give
a general feeling of annoyance, discontent, or even fear. Apart from the intensity
of the noise, other physical characteristics such as frequency and rhythm (impulse
versus nonimpulse sounds) are of relevance. Noise with low frequency components,
for example, require lower guideline values. For impact noise, both the maximum
sound pressure and number of noise events must be considered.
During the day, few people are annoyed at noise levels below 50 dB(A). How-
ever, sound levels during the evening and night should be 5-10 dB lower. A WHO
expert panel (Bergiund et al., 1999) developed the guidelines in Table 8.7 for com-
munity noise in specific environments.
therefore relate to the extent of the impact on the population, i.e., the propor-
tion the population suffering from serious sleep disturbance, the most serious ad-
verse effect of noise. According to the principles of risk assessment, health effect
data constitute the necessary background information for the formulation of stan-
dards. The WHO suggests that from a medical point of view, the proportion of
very annoyed people in the population of urban centers should not exceed 5%
(Rylander, 1992). Politicians and administrators who are responsible for setting
noise standards should bear this suggestion in mind, as well as the guidelines in
Table 8.7.
Many things can be done to alleviate noise-related problems. Residents can
be protected from industrial noise by zoning laws that prohibit the mixing of in-
dustry with residential areas. (This is particularly important for informal settle-
ments, which are often forced to develop in industrial areas because these areas
are the only viable option for the very poor.) Zoning laws can also separate res-
idential areas from major transportation routes and airports. Municipal bylaws
can prevent people from making unnecessary or excessive noise. Regulations can
also place restrictions on motor vehicles, specifying that they must be in good
running condition and that they must have appropriate mufflers. The difficulty
with all of these solutions is that they require active participation on the part of
government. Large-scale changes in laws are notoriously difficult and slow to be
implemented.
There is little residents can do independently to reduce the amount of noise
in their lives. Hearing protectors can be worn to reduce the likelihood of direct
hearing loss, and they may reduce sleeplessness due to background noise. But
HUMAN 5ETLEMENT AND URBANIZATION 303

TABLE 8.7
GUIDELINE VALUES FOR COMMUNITY NOISE IN SELECTED ENVIRONMENTS
Time
Specific Base
Environment Critical Health Effect(s) Leq [dB] [hours]
Outdoor living area Serious annoyance, daytime and evening 55 16
Moderate annoyance, daytime and evening 50 16
Dwelling, indoors Speech intelligibility and niodcrate 35 16
annoyance, daytime and evening
Inside bedrooms Sleep disturbance, night-time 30 8
Outside bedrooms Sleep disturbance, window open 45 8
(outdoor values)
School classrooms Speech intelligibility, disturbance of 35 during
and preschools, information extraction, class
indoors message communication
Preschool, Sleep disturbance 30 sleeping
bedrooms, indoor -time
School, playground Annoyance (external source) 55 during
outdoor play
Hospital, ward, Sleep disturbance, nighttime 30 8
rooms, indoors Sleep disturbance, daytime and evenings 30 16
Industrial, Hearing impairment 70 24
commercial and
traffic areas, indoors
and outdoors
Ceremonies, Hearing impairment 100 4
lestivals and (patrons: <5 times/year
entertainment events
Public addresses, Hearing impairment 85 1
indoors and outdoors
Music and other Hearing inlpairnlcns 85 1
sounds through (under
headphones/ headphones)
earphones
Adapted from WI-jo, 1999
this solution does not address the real cause of the problem and brings new prob-
lems of its own (discomfort, inability to hear important low-intensity noise).
Motor Vehicle Accidents

Motor vehicle usage has increased dramatically around the globe. In 1950, there
were approximately 53 million cars on the world's roads; this has increased more
than eightfold over the last four decades, with the global automobile fleet now
over 430 million. This represents an average growth of approximately 9.5 mil-
lion automobiles per year (WHO, 1992c). While the growth rate has slowed in
the highly developed countries, population growth and increased urbanization
and industrialization have accelerated the use of motor vehicles elsewhere. The
growth of motorization exceeds the growth of population-5.2% per year be-

Africa 114.2
East Asia & the Pacific 128.9
South Asia 3.1
Central & Eastern Europe 71.5
Middle East • 44.6
Latin America & Caribbean • 67.9
China 1.48
United States 561
Figure 8.5 Passenger cars per OECD 366
1000 population by region and
selected countries, 1993. From 0 100 200 300 400 500 600
WRI, 1996, with permission. number of cars per 1,000 population
tween 1960 and 1989, compared to 2.1% per year, respectively. By early next
century, if current trends continue, the rapidly developing areas of the world (es-
pecially Asia, Eastern Europe, and Latin America) and the Organization of Eco-
nomic Cooperation and Development (OECD) Pacific region will have as many
vehicles as North America and Western Europe, although per-capita rates will
remain substantially lower. Figures 8.5 and 8.6 show the 1993 per-capita num-
ber of passenger cars in selected regions and projected trends in worldwide mo-
tor vehicle ownership, respectively.
In 1993 an estimated 885,000 people died in traffic accidents (WHO. 1995a).
Globally, this makes traffic accidents the second-leading cause of death for peo-
ple aged 5 to 44. With the majority (70%) of these deaths occurring in devel-
oping countries, in some places it is the number-one killer for this age-group.
For example, in Nigeria, motor vehicle accidents account for one-half of the to-
tal deaths for this age-group.
In developed countries, the mortality rate for motor vehicle accidents has been
dropping over the last 70 years, even as the rate of vehicle ownership has dra-
matically increased. This has been attributed to the gradual improvement of road
conditions, the establishment of higher vehicle safety standards, and increased
driver training. In developing countries, however, the opposite has occurred. The
rate of fatal injuries per registered vehicle climbed to 300% since 1968 in Africa.
One reason for this is that each incident frequently affects many people—for ex-
ample, when a motor vehicle accident involves a crowded bus. Moreover, mo-
900
800
700
600
500
400
300
200
Figure 8.6 Worldwide motor 100
vehicle ownership, 1970-2010. 0
1970 1980 1990 2000 2010
From WRI, 1996, with permis-
sion. Year

torized vehicles have been introduced over a relatively short time span, and gov-
ernments have been unable to implement the necessary safety measures quickly
enough, resulting in an increase in the associated mortality rates.
Globally, two-thirds of motor vehicle—related fatalities involved pedestrians,
predominantly children and the elderly. Several factors contribute to this phe-
nomenon. One is that pedestrians sustain greater injuries and are more likely to
be injured or killed in an accident than passengers of enclosed vehicles, even if
the accident is not particularly severe. Second, in poorly planned urban areas
(especially in developed countries), roads are used by all forms of traffic with lit-
tle or no separation of vehicles and pedestrians. This naturally increases the risk
of pedestrian involvement in motor vehicle accidents. Additionally, children or
elderly pedestrians may be more vulnerable because of their decreased sensory
perception. Children are often unable to identify the source of a sound and they
have difficulty making simple distinctions in direction. They are also greatly dis-
advantaged by their lack of experience with motor vehicle traffic. The elderly fre-
quently suffer from a decreased ability to see and hear and walk slower. They
also may experience mental confusion and are often unable to cope with the
rapid changes in their environment, making it more difficult to navigate their
way through traffic.
Mortality and morbidity rates for particular countries are also associated with
motorcycle/bicycle ownership rates. Drivers and passengers of these types of ve-
hicles experience the same kind of vulnerability to serious injury or death as
pedestrians. For bicycles, those most at risk are again children and the elderly,
for many of the same reasons that they are at risk as pedestrians. For rnotorcy-
des, those most at risk are 15-25 years old.
TI-iF "HEAT THY CITIES" APPROACH TO PREVENTION
Promoting Urban Health

Rapid urbanization has made it increasingly important to deal with issues that
affect the health of urban populations. It is estimated that by the end of this
decade, roughly half of the world's population will live in urban centers. The ba-
sic idea behind the Healthy Cities Program is to improve urban health by start-
ing interscctoral action for health at the local level WHO, 1995h; Hancock, 1996.
Therefore, the major objective of this program is to place health promotion high
on the political agenda of municipal governments. In addition to this local po-
litical commitment, the cooperation with various community groups, neighbor-
hood associations, and health care providers is essential.
The healthy city concept refers to a process, not just an outcome. A healthy
city is not necessarily one that has achieved a iarticular health status. It is con-
scious of health as an urban issue and tries to improve its environments and ex-
pand its resources so that people can support each other in achieving their high-
est potential. This general principle is expressed more specifically in a description
of the 11 qualities that a healthy city should strive to achieve, as indicated in
Box 8.5. Thus, any city can he a healthy city if it is committed to health and has
a structure and process to work for its improvement.

BOX 8.5
The Qualities of a Healthy City
A city should strive to provide the following:
• A clean, safe physical environment of high quality (including housing quality)

• An ecosystem that is stable now and sustainable in the long terni
• A strong, mutually supportive and nonexploitative community
• A high degree of participation and control by the public over decisions aflecting
their health and well-being
• The meeting of basic needs (for food, water, shelter, income, safety, and work)
for all the city's residents
• Access to a wide variety of experiences and resources, with opportunity for am-
ple interactions
• A diverse, vital, and innovative city economy
• The encouragement of connection with the past, with the cultural and biological
heritage of city dwellers, and with other groups and individuals
• An optimum level of appropriate public health and sick care services accessible to
all
• High health status (high levels of positive health and low levels of disease)
Source. WHO, 1995b.
Characteristics of a Healthy Cities Program

Political commitment is the first step in working toward a healthy city. Cities
that have entered the WHO network have been requested to make such com-
mitments. They have been asked to formulate intersectoral health promotion
plans with a strong environmental component and 10 secure the resources for
implementing them. These should include an interscctoral political commit-
tee, mechanisms for public participation, and a program office with full-time
staff. Central to the initial commitment to the WHO is an agreement to report
back regularly on progress and share information and experience. Since each
urban center has its own specific health problems and will therefore empha-
size their most relevant actions to improve health, all Healthy Cities programs
will be different with regard to their content. However, the framework of each
program is identical and all healthy cities share a number of important char-
acteristics:
• All programs are based on a commitment to health. The holistic nature of

health is affirmed and the interaction among its physical, mental, social, and
spiritual dimensions is recognized. It is assumed that health can be improved
through the cooperative efforts of individuals and groups in the city, if pro-
motion of health and prevention of disease are recognized as priorities.
• Each healthy city requires political decision making for public health. City gov-
ernment programs such as those addressing housing, the environment, edu-

cation, and social service have a major effect on the state of health in urban
centers. The aim of Healthy Cities programs is to strengthen the contribution
of such programs to the promotion of health by influencing the political deci-
sions of the city council.
• The programs stimulate intersectoral action. The intention of Healthy Cities
programs is to mediate between all parties that influence the determinants of
health, including industry, various city departments, and other bodies, and to
bring them together to negotiate their contribution to improve the urban en-
vironment. In this way, organizations or individuals working outside the health
sector change their activities so that they contribute more to a healthy envi-
ronment. An example of such iniersectoral action is urban planning that sup-
ports physical fitness by encouraging the linkage of "active" transport with pub-
lic transport and by providing ample green space within a city for recreation.
• The programs promote a more active rcle for the general public. The program
provides the means for having a direct influence on the activities of city de-
partments and other organizations. In addition, health can also he promoted
on the individual level by changing individual views on health issues, lifestyle
choices, and use of health services.
• All programs strive to promote health by stimulating the constant search for
new and innovative ideas and methods. The success of Healthy Cities programs
depends upon the ability to creatc opportunities for innovation. This can he
achieved by spreading knowledge of innovative methods, creating incentives
for innovation, and recognizing the achievements of those who experiment
with new policies and programs.
All of the above indicated actions (political decisions, intersectoral action, com-
munity participation, and innovation) contribute to the outcome of a program:
a heahhy public policy. The success of a Healthy Cities program is reflected in
the degree to which policies that create settings for health are in effect through-
out the city. Program participants have achieved their goals when homes, schools,
workplaces, and other parts of the urban environment become healthier settings
in which to live.
From Program to Movement
The dissemination of Healthy Cities strategies has been greatly accelerated by the
growth of national and subnational networks. Although the Healthy Cities pro-
gram was introduced in Europe, the influence of the program extends beyond
the boundaries of this region. Regional networks have been developed in Aus-
tralia, Canada, the Maghreb region (Northern Africa), Iran, Malaysia, the United
States, and Middle and South America. Participation in Healthy Cities programs
in developing countries is also encouraging (WHO, 1995b). Through the success
of the developed networks, the number of communities cooperating with the of-
ficial programs is becoming a sort of movement that is growing far more rapidly
than expected.
In 1996 World Health Day was dedicated to the Healthy Cities program and
about 1000 cities committed themselves to urban health promotion. In addition,
a Safe Communities Network has grown up as well, and the United Nations En-

vironment Program (UNEP) is monitoring a Sustainable Cities network based on
similar principles.
Healthy City Actions

There is no ideal model for a healthy public policy, and the type of actions taken
or emphasized is quite different among projects. A number of actions are briefly
illustrated here.
Actions for equity: Inequities are caused by economic factors as well as by
the use of skills that people have to take advantage of life opportunities. In-
equities in access to a healthy physical environment are as important as socioe-
conomic inequities. They are reinforced by standard town planning regulations
or through the absence of policies focusing on equal access to city amenities. A
number of cities have taken action to improve such equity, including Liverpool
and Milan. Liverpool is one of the European cities that has been hardest hit by
economic recession, resulting in the socioeconomic inequities of unemployment
and racial tension. In this city a wide range of integrated activities has been un-
dertaken that affect the environmental, social, and health services components
of the prerequisites for health of the district population. In Milan it was found
that women and foreigners had substantially less access to a broad range of health
and social services. Milan tried to tackle the problem by conducting information
campaigns that targeted specific groups and by functionally improving the ac-
cessibility of services.
Actions for supportive environments and sustainability. The environments
in which people live determine their quality of life, health, and well-being. Some
Healthy Cities programs try to inform people about their environments and some
explicitly try to transform and improve environments. In Denmark, a good ex-
ample of supportive environments is the Horsens initiative to build a new block
of houses to promote integrated living. In the new living area, houses and flats
for people with disabilities are located next to hotning for those without disabil-
ities, and old people will live together with younger generations. Furthermore,
houses are built in a way that conserves energy, and sufficient green spaces are
provided. In Sofia, the old diesel-powered public transport was replaced by trol
Icy buses and electric trarns to diminish air pollution.
Actions for community involvement. If people actively participate in de-
termining actions for health, they will ensure that services and activities under-
taken are appropriate, and they will be more satisfied with the result. The Healthy
Cities Program in Liege has encouraged community groups and organized meet-
ings in neighborhood centers. A media campaign was started, and people were
supplied with brooms, garbage cans, and other cleaning materials to help the mu-
nicipal services clean up the city. More recently, children have been involved in
a number of similar programs. In Seattle children were asked to draw, paint, or
write about their neighborhood and how they would like it to be. This type of
rogram has since been carried out in PCcs, Eindhoven, Munich, Copenhagen,
Barcelona, and Horsens.
Actions for reorienting health services. Because health services are a ma-
jor concern of residents in cities, many cities are making a major effort to reori-
ent health services to meet the needs of the population. However, in some coun-
HUMAN SE1TLEMENT AND URBANIZATION 309

tries, health services are a regional or national responsibility and city adminis-
trations cannot interfere with the quality and quantity of health services. Nev-
ertheless, some cities have initiated innovative pmgrams to improve health ser -
vices in urban areas. For instance, in Sofia, actions have been undertaken to
renovate primary health care facilities for children with chronic diseases. Bre-
men has developed an action plan for elderly people through an intersectoral
and integrated policy to improve the accessibility of services, provide support sys-
tems, and facilitate self-help groups.
Study ()liecOnfls
Is urbanization occurring in your area? If so, why? If not, why not, and
do you think it will occur in the near future?
Is noise a problem in your area? If so, what are the main sources?
Outline what you would do to decrease the incidence of road injuries in
your jurisdiction.
. I-low would you apply the principles of' Healthy Cities" in your jurisdic-
tion?

vll~
HEALTH AND ENERGY USE
LEARNING OBJECTIVES

• describe the importance of energy to health
• identify the health effects (direct and indirect) associated with the various
energy sources
• address public concerns regarding various energy sources
CHAPTER CONTENTS
Human Energy Needs Hydropower

Energy Needs for Health and Use of Hydroelectric Power
S ustainability Direct Effects on Health
Energy Consumption and Indirect Effects on Health
Requirement Trends Mitigation by Environmental
Biomass Fuels Management
Use of Biornass Fuels Nuclear Power
Direct Effects of Biomass Fuels Use of Nuclear Power
Indirect Effects of Biomass Fuels Fusion
Less Polluting Household Energy Stochastic (Non-Threshold) Effects
Sources Deterministic (Threshold) Effects
Fossil Fuels Safety Approaches
Use of Fossil Fuels Alternative Energy Sources
Direct Effects on Health Comparing Risks
Indirect Effects on Health
Priorities for Action
Pollution Prevention Strategies
HUMAN ENFPGY NEEDS
Energy Needs for Health and Sustainability

Energy can have direct and indirect, beneficial and detrimental, effects on health.
It is essential for socioeconomic development. Without it, communities would
not be able to cook their food, and would be more susceptible to infections and
food poisoning. Nor could they maintain systems for heating, transportation, com-
munication, and the production of materials. Energy requirements are summa-
rized in Table 9.1.
311
TABLE 9.1
SUMMARY OF ENERGY NEEDS
Basic human needs (heating, lighting, cooking)
Agriculture (irrigation, mechanization)
Urbanization (basic Services)
Transportation
industrial production
The patterns of energy use and production are key characteristics of all soci-
eties. The challenge is to produce the amount of energy needed while imposing
the least possible health risk and environmental detonation. The availability of
energy often determines the nature of a region's sicloeconomic development.
For development to be sustainable, energy sources must also be dependable, safe,
and environmentally sound.
It is widely accepted that an assessment of the total risk of an energy source
must include an evaluation of all the risks across the energy cycle: (a) material ac-
quisition and construction, (b) emissions from material acquisition and energy
production, (c) operation and maintenance, (d) energy back-up systems, (e) en-
ergy storage systems, (f) transportation, and (g) waste management.
Energy Consumption and Requirement Trends

Varicus forms of development require many forms of development, resulting in
a number of trends in global energy consumption. Overall energy consumption
increased by about 2.2% per year before 1950; between about 1950 and 1970,
energy consumption increased by 5.2% per year; but since the energy crisis in
the 1970s, the demand for energy has slowed back to an increase of 2.3% per
year. The total energy consumption over the period of 20 years (1973-1993) was
490% greater than in the previous 20 years (WRI, 1996, see Fig. 9.1).
Although the developing world's population far exceeds the population in in-
dustrialized countries, the latter consumes far more energy. In 1991, the industri-
alized countries of the Organization for Economic Cooperation and Development
(OECD) accounted for 52.4% of the world's total energy consumption, while they
were responsible for only 37.4% of global producticn (WRI, 1994) and have only
about 22% of the world's population. These ratios have remained reasonably con-
350
300 oa
250
.----
- 200
OECD countries
>< 150
ID
Developing
100 countries
50 — Transition countries
(tormer Soviet Union & Central Europe)
OF- Figure 9.1 Trends in energy
1973 1978 1983
11 1988 1993 Consumption. 1973-1993. From
Year WRI, 1996, with permission.

100
Solids
80
60
C
a
>< Gas
.- 40
Hydro — —
011
Figure 9.2 Commercial energy —
•- Nuclear
———
consuniptmn by source, indus-
trialized countries, 1971-91.
1974 1978 1982 1986 1990
From WRI, 1994, with permis- 1970
Si OIl. Year
slant since 1965, although some current projections suggest that the energy con-
sumption growth rate will be highest in the developing countries over the next
several decades (4.5% per year versus 1.5% per year in developed countries)
(UNEP, 1992a). In fact, according to the U.S. Office of Technology Assessment,
commercial energy use in developing countries could triple over the next 30 years.
In some countries demand is growing more than 10 11% annually (OTA, 1992).
With industrialization, there is a trend away from reliance on biomass and other
renewable energy sources and toward dependence on fossil fuels, which are non-
renewable. About 100 years ago, noncommercial sources of fuel (fuel wood, agri-
culture [e.g., dung]) accounted for about 50% of the total energy used in the world.
Today, this type of fuel only comprises about 12% of the total energy use in the
world, although about two billion people depend on noncommercial products for
their fuel. This percentage has remained constant since about 1970 (UNEP, 1992a).
Figures 9.2 and 9.3 show how the use of various energy sources has changed
between 1971 and 1991 in the industrialized countries, and developing countries
50
40
30
a)
=0
a Solids
20
Liquids
•. -—
10
Figure 9.3 Commercial energy

consumption by source, devel- 0
oping countries, 1971-91. From 1970 1974 1978 1982 1986 1990
WRI, 1994, with permission. Year
HEALTH AND ENERGY USE 313

respectively; it should be noted that there are wide variations by region within
these groups. Solid energy sources include wood, other biomass, and coal. The
various uses of energy, and typical sources for these uses, are summarized below.
Basic Human Needs (Heating, Lighting, Cooking) Approximately 50% of the

global population, predominantly in developing countries, is dependent on bio-
mass fuels (i.e., wood, crop residues, animal dung) for domestic tasks. Other do-
mestic energy sources include fossil fuels. Some of these are burned raw, like
coal or lignite ("brown coal"), and others are processed, like kerosene and oil.
Some households use electricity produced from fossil fuels, especially in the de-
veloped world. A small proportion of households have their energy needs met
with electricity produced from renewable sources, such as hydropower.
Agriculture (Irrigation, Mechanization) Only 4.5% of total global energy con-

sumption is due to agricultural use. On a per-capita average, consumption in the
developing world is about one-tenth that of the developed world. Most of the
energy consumed in agriculture in poorer countries is spent on fertilizers, whereas
in richer countries it is consumed by farm machinery.
Urbanization (Basic Services) Urbanization is often accompanied by industrializa-

tion, as industry requires the pooling of resources and labor. Energy needs in urban
areas are therefore greater than in rural areas, because of industrial requirements
and the provision of basic services (i.e., water, water disposal) to urban populations
is energy-intensive. Statistics on the energy costs of urbanization are difficult to es-
tablish, but it is clear that in the developing world, where many basic urban services
are not provided and industry is not as prevalent, energy consumption is much lower
than in equivalent urban centers in the developed world. On the other hand, en-
ergy efficiency may be much lower in rural areas and in developing societies.
Transportation Energy consumption by transportation is tightly linked to ur-

banization and industrialization, as the need for movement of goods and services
into and out of urban/industrial areas is greater than in rural areas, which are
traditionally fairly self-reliant. The major user of energy in transportation is the
motor car.
Industrial Production Socioeconomic development is linked to industrialization,

which is greatly dependent on energy. In the developed world, where industry
is entrenched, industrial production uses 40%_60% of the total energy consumed.
In the developing world, only 10%_40% of the total energy consumption is ac-
counted for by industry, but this percentage is increasing. The rate of growth,
however, is as yet unable to keep up with population growth in these regions.
This results in an increase in energy consumption without a corresponding in-
crease in socioeconomic development.
Hydroelectric power is a renewable form of energy that is being increasingly
used throughout the world, but it may carry a high cost in ecosystem damage.
Nuclear energy, in its traditional form of fission, is nonrenewable but requires
only small amounts of fuel. Many countries have come to rely on nuclear en-

crgy, including France and the Ukraine. Others, such as Sweden and the United
States, have not expanded their nuclear energy capacity in recent years because
coal use has
of concerns over safety and cost. Since the oil crisis in the 1970s,
grown in OECD countries. For their oil-hungry economies, OECD countries de-
pend on imports, primarily from the Gulf states.
As urbanization and industrialization proceed, energy is used increasingly for
functions that did not exist or were relatively minor in traditional cultures, e.g.,
bright lights, illuminated signs, air conditioning, heating of office buildings and
shopping malls, entertainment (television, radio), and computers. These cultural
changes in energy consumption may have a major impact on global energy re-
quirements. Information technology may increase the efficiency of energy use
(e.g., as a result of teleworking, replacing traditional mail and face to face meet-
ings by e-mail and virtual conferences, respectively).
BIOMASS FUELS
Use of Bioniass Fuels

Half of the world's population depends on biomass fuel for domestic use. The
hazards associated with them have global repercussions. Biornass fuels include
wood, logging wastes, sawdust, animal dung, and vegetable matter. These are of-
ten the only fuel sources available in the poorest rural areas, and as conditions
deteriorate for the urban poor, it becomes their only option as well. Because of
incomplete combustion, biomass smoke contains respirable particles, carbon
monoxide, nitrogen oxides, formaldehyde, and hundreds of other simple and
complex organic compounds, including polvcyclic aromatic hydrocarbons. It has
been shown in many studies that the concentration of these pollutants often ex-
ceeds the WHO guidelines by a factor of 20 or more (see studies cited in Smith,
1991). The pollutant load for each meal cooked is much higher for biomass than
for any other energy source (Fig. 9.4). Because of these large concentrations, and
the total number of people involved, the total human exposure to biomass pol-
lutants is large. Most studies of the health effects of these air pollutants from en-
ergy use have been on ambient (outdoor) air pollution, and extrapolation to in-
door air pollution situations is necessary. (Smith, 1991).
40 20
-D
30 15
Par5cuiates
per standard a
U) CD
a \me&
CO per
5 20 standard 10
a
.5 - mea 2
0 Sn
CD
0
10 05
a
Figure 9.4 Amount of indoor a
air pollution for each meal

cooked. From Smith, 1991, Dung Crop Wood Kerosene Gas
00
with permission. res!dues

Direct Effects of Biomass Fuels
The problems resulting from biomass fuel combustion are worsened in urban ar-
eas, as fuel use is often completely contained within the dwelling and is inevitably
accompanied by poor ventilation. Populations living in cool regions that use bio-
mass fuels as their indoor heat source are especially adversely affected. Chapter
5 discussed sortie of the health risks associated with the combustion of airborne
contaminants. The greatest health effects are those caused by smoke inhalation.
The smoke may come from coal, cooking oil, or wood and may be used for heat-
ing or cooking. Indoor air quality is a serious hazard to health in many devel-
oping countries, such as Nepal, China, and India. Decreased lung function has
been noted in tests on Nepalese women as a result of the time spent near the
stove. This was also found in Chinese women using coal stoves compared to those
using gas stoves. Respiratory symptoms have been associated with the use of bio-
fuel in India, Malaysia, and in several Chinese studies among different age groups,
as summarized by the WHO (1991b). A Nepalesc study, for example, also showed
that household smoke exposures was associated with an increased rate of acute
respiratory infections in children (Pandey et al., 1989), one of the largest causes
of mortality in Nepal. A study of pregnant women in India has noted that hio-
fuel smoke was a significant risk factor for stillbirth (Smith, 1991).
Lung cancer and chronic bronchitis are more common among women in some
of these societies because of the time they must spend in the home. This has
been studied in Nepal, India, Japan, and China (Smith, 1991; WHO, 1992). The
resulting respiratory problems tend to compound each other, creating a vicious
cycle of pathologies.
Domestic fuel combustion is also accompanied by a risk of accidents due to
open fires and poorly designed stoves. Other direct health effects include prob-
lems encountered in the collection of fuel and tending of fires. All of these haz-
ards are experienced most directly by women, who are usually responsible for
domestic tasks, and children, who spend much of their time in the home and
are most physically vulnerable. Tables 9.2 and 9.3 describe the major health risks
TART F Q 2
ADVERSE EFFECTS OF BIOMASS FUEL PRODUCTION AND COLLECTION
ON HUMAN HEALTH
Function Possible Health Effects
Processing/preparing dung cakes Fecal/orallenteric infection
Skin infection
Charcoal production CO/smoke poisoning
Burns/trauma
Cataracts
Gathering fuel Trauma
Reduction in infant/child care
Bites from venomous snakes, spiders, leeches, insects
Allergic reactions
Fungus infections
Severe fatigue
Source; WEtO, 199 lb.

TABLE 9.3
ADVERSE EFFECTS OF BIOMASS COMBUSTION ON HUMAN HEALTH
Effects of smoke (acute and subacute) Conjunctivitis, blepharoconjunctivitis
Upper respiratory irritation, inUamniation
Acute respiratory infection
Effects of toxic gases (e.g., CO) Acute poisoning (Ironi CO)
Cardiovascular diseases
Effects of smoke (chronic) Chronic obstructive pulmonary disease
C hronic bronchitis
Adverse reproductive Outcomes
Cancer (lung)
Acute effects of heat Burns
Chronic effects of heat Cataracts
Ergononuc eflcus of crouching over stove/lire Arthritis
Sort r c WHO, 1901b.
associated with the dependency on biomass fuel, addressing adversc effects of

fuel processing and fuel burning, respectively.
indirect Effects of Biomass Fuels

The most significant indirect health effects of biomass fuel consumption arise
from the deforestation and greenhouse effect that are caused by this kind of con-
sumption unless the vegetation materials used are replanted at the same rate.
These effects will he discussed in Chapter 11.
Less Polluting Household Energy Sources

It is possible to minimize the problems associated with biomass fuel combustion.
Almost all biomass fuel combustion is for domestic purposes. The commonly used
open fire pits provide the least efficient method of combustion, but unfortunately
are often the only option available. Biomass stove technology is well developed
(Smith, 1991), and households can reduce the amount of fuel they require by
using more efficient stoves. Cutting the amount of fuel required for domestic
tasks means less work for the family, and lessens the rate of deforestation. Of
most importance for household residents is that better stoves can also reduce
emissions, which pose the greatest threat to their health. Indoor emissions can
he further reduced with the installation of chimneys and hoods on stoves. There
are no studies, though, that definitively measure the improvement by the addi-
tion of a chimney, and the costs of adding one can make this option difficult
(Smith, 1991). The most cost-effective method of reducing emissions is often sim-
ple household rearrangement, by placing the stove or fire in a position where
more of the emissions can flow outside. This access to outside air circulation re-
sults in less immediate harm to human health.
Although it has been suggested (WHO, 1991b) that alternative fuel sources to
biomass fuel, such as kerosene, liquid petroleum gas (LPG), and electricity are good
alternatives, each of these has its disadvantages. Air pollution from kerosene stoves
(carbon monoxide and particulate matter) may be a considerable problem, and
more research is required before substitution programs can be reasonably sug-
gested. Liquid petroleum gas and electricity are both very expensive, making their

widespread implementation largely impossible. It is probable that those households
now dependent on biomass fuels will continue to use them for the foreseeable fu-
ture. Biornass fuel upgrading, by the production of briqucttes (by compression of
charcoal), or biogas (methane from fermentation of various biomass sources) may
be an intermediate solution, as they burn more efficiently. Of the two, biogas is
the best alternative, as charcoal combustion produces many harmful emissions.
FOSSIL FUELS
Use of Fossil Fuels

Fossil fuels include oil, coal, and natural gas. All of these energy scurces are non-
renewable. They are derived from solar energy trapped, due to photosynthesis,
in the form of fossilized plants, and were created over millions of years. In 12
months the world consumes an amount of fossil fuels that took one million years
to create. Despite awareness of this, and recent conservation efforts, these fuels
continue to provide almost 90% of the world's commercial energy. Most of these
fuels are converted into electricity before consumption, but some of them are
burned raw. Even though there are efforts to convert to alternative fuels, oil is
still the principal source of energy, supplying 38% of the world's energy needs.
Coal, used extensively during the industrial revolution, accounts for 30%, while
natural gas accounts for 20% (WHO, 1992d). Thus, nonrenewable sources of en-
ergy account for the vast majority of global energy needs.
In the past three decades, transportation, which is primarily supported by fos-
sil fuels, has expanded rapidly (see Chapter 8). The known reserves of oil and
natural gas may be consumed within the next 30 to 40 years. Coal reserves may
last another 200 years, but the remaining coal is of very low quality, and its corn-
bustion will produce considerably less energy than the coal now being consumed.
Along with problems of renewability come multiple hcalth hazards. Thcse haz-
ards exist at every point along the route of fossil fuel consumption, from ex-
traction and processing (Table 9.4) to combustion (Table 9.5), and have both im-
mediate and long-term effects.
TABlE 0 4
HAZARDS ASSOCIATED WITH FOSSIL FUEL EXTRACTION AND PROCESSING
Fuel Location Hazards and Effects -
Coal Underground mines Coal workers' pncumoconiosis (CWP( or "black
lung," silicosis, fires/explosions, injuries
Open-pu mines Industrial tironchitis, chronic cough, accidents
(mining, transport)
Oil Oft-shore developments Accidents caused by weather, explosions
Land oil fields Dermatitis (from long-term expostire to crude oil),
accidents/explosions
Refineries Exposure to hydrocarbons (known carcinogens)
Natural gas Deposits Hydrogen sulfide exposure, accidents/explosions
Refineries Exposure to hydrocarbons (known carcinogens),
accidents/explosions

TABLE 9.5
HEALTH HAZARDS ASSOCIATED WITH FOSSIL FUEL COMBUSTION
Fuel Method of Combustion Associa ted Hazards and Effects°
Coal Domestic fires Acute respiratory infections, chronic
(i.e., using raw coal) ltmg diseases, lung cancer
Industrial consuospfion Accident/lire, air pollution ellects
Oil Industrial consumption Accident/lire, air pollttiton effects
Vehicles Motor vehicle accidents, air pollution
ellects
Domestic consumption Indoor air pollution effects
(e.g., kerosene stoves)
Natural gas Industrial consumption Air potltttanls
Domestic use (cooking/heating) Air pollutants, asphyxiation, explosions
'The different types of air pollution are discossed in Chapter 5
Direct Effects on Health

Combustion of fossil fuel is the single greatest cause of atmospheric pollution. As
with biomass fuel combustion, the etTiissiofls from the incomplete combustion of
fossil fuels that are of greatest concern, for both human and environmental health,
are sulfur oxides, suspended particulate, nitrogen oxides, carbon monoxide, poly-
cyclic aromatic hydrocarbons, and carbon dioxide. These emissions, and their di-
rect health effects, were discussed in Chapter 5. Indoor emissions of sulphur ox-
ide particulates, nitrogen oxides, and carbon monoxide can he of great concern.
This applies to coal especially, but also to natural gas and oil. The more impor-
tant though less common circumstances affecting human exposure are those in
which the combustion products pollute the indoor environment directly, through
faulty flues, and from leaks in fixed appliances. The single most dangerous chem-
ical hazard from indoor combustion of fossil fuels or biomass is carbon monox-
ide. Poor ventilation and inadequate air supply may lead to high levels in closed
rooms, enough to cause death. The burning of fossil fuels also exposes the user
to the very real risk of accidental fires and explosions. Where stoves and heaters
are inadequate, the risk of fires is much greater.
Other direct health effects from fossil fuels include the occupational risks from
the mining of coal. These effects range from cave-ins and gas explosions to pneu-
moconiosis (from the inhalation of coal dust), as described in Chapter 10. Nonethe-
less, as discussed in Box 9.1, investigations and consequent advancements in coal
technology have been made. While the risk of developing these serious diseases
has been decreasing recently through the use of modern technologies that protect
mine workers, the risks of injury from mining and transportation of coal have
tended to change less. Synthetic liquid fuels made from coal, heavy oil, and min-
eral deposits of hydrocarbon in shale or sandstone (kerogen) differ in the chemi-
cal composition of the crude oil that results. They tend to be more toxic and may
be more carcinogenic. The synthetic fuels are potentially more hazardous to work-
ers than petroleum, depending on the source, process and exposure.
Risks associated with the petroleum and natural gas industry are less than
those of coal production and are most associated with injuries. Generally, it is
the exploration for new sources of fuel and the drilling and servicing of wells

BOX 9.1
The Swedish Coal-Health-Environment Project
In November 1979, the Swedish Government commissioned the Swedish Power Board
to investigate and report on how the health and environmental problems arising from
an increased use of coal in Sweden could be solved. The project's investigators ana-
lyzed the various stages of the use of coal and the disturbances that can arise from such
use. The emission of sulfur and nitrogen oxides, toxic metals, and dust is, of course,
not peculiar to coal, but can occur to varying degrees in the burning of other fuels.
Large resources of coal, including the much-desired low-sulfur coal, are avail-
able in many parts of the world, including the United States, Poland, the former So-
viet Union, western Canada, Australia, and Colombia. Coal, like peat and wood, is
not homogeneous, but rather contains a varying content of trace elements. Mer-
cury is one of the most iniportant toxicologically.
The occupational hazards associated with coal are well known. Dustiness oc-
curring in the transport and handling of coal can occur particularly in warm and
windy weather conditions. The risks of harmful dust can be eliminated or strongly
reduced by rational working methods and technical solutions. This also applies to
the transport and handling of waste products. Special care must he taken at the
point loading takes place at the installation and when loading the products at the
dump (see Fig. 9.5). Dry ash should be handled in fully enclosed systems.
The Swedish Project concluded that adverse effects on the respiratory system
were not expected to occur with the burning of coal in Sweden, given the use of
modern and effective techniques. Investigations into the content of mutagenic and
carcmogenic substances in the emissions have shown that the large modern, well-
run, coal-fired and oil-fired installations emit only a small quantity of rnutagenic
materials. However, emissions per energy unit of mutagenic substances can be con-
siderably greater from small installations.
The Power Board considered that the use of coal, which involves replacement
of oil, affecied the level of methylmercury in fish to a small degree. There is a risk
of increased levels in fish in acid-sensitive lakes close to large point sources, such
as a coal-fired powered station, if prudent measures are not taken. Siting, local con-
ditions, and the measures taken in such cases determine the extent to which an in-
creased risk occurs. It was noted that tighter regulations in this area can very well
prove essential to bring down mercury risks to acceptable levels.
On the assumption that fly ash with too high a radioactivity is not used in build-
ing materials for residences, and that drinking-water wells are not situated in the vicin-
ity of waste dumps, the techniques available for transport and disposal of waste prod-
ucts from the combustion of coal were deemed to be sufficient to avoid risks of negative
results. The project concluded that coal can he used as replacement for oil in district
heating and power stations and within industry, in a way that is acceptable for health
concerns, if coal is used in well-maintained installations that are big enough to make
it feasible to use environmentally safe technology. The production of electricity in coal-
fired powered stations was similarly judged to be acceptable. It was noted that special
investigations into local and regional conditions should he conducted at each site be-
fore deciding the extent of electricity production that is possible.
Coal, like other fossil fuels, contains comprunds of an undesirable nature that
are released during combustion. Many of these may affect health. Apart from the
annoyance of people, local effects on the respiratory tract, effects on other organ
systems, and genotoxic effects (e.g., cancer) can occur. Impurities in effluent from
refuse dumps, particularly metals, can lead to systemic effects.
SOUrCe. SCHEP, 1983.
320
Radionuclides
Polycyclic ' Trace

organic elements
material
Carbon dioxide
ParticulatesSulphur oxides
, Nitrogen oxides
AIR
1'
Coal dust Coal dust
F'
I I I
I __________
MEMEN
ME Iiit4 I
.I
Beneficiation Plant ' Truck Utility Ash Sludge
F bou r
plant waste
%
I %
I
''
rA'
,
I
I
Train
I
Waste I ' Waste

disposal ' I disposal
• I Industry.. .
17-1
LAND
I
I ____________
---
_________________
-
I • Barge II
I
I • I
I I
I I
•
I I
I l Slurry A I
pipeline :
I •
I I I
I I I I
I
I I I
WATER I
:
. Leachates Discharge Dissolved u

yI
solids y
Leachates Dissolved Water Leachates
and suspended consumption
solids
Figure 9.5 Various stages in the handling of coal in Sweden and the environniental dis-
turbances that can occur. From SCHFP, 1983, with permission.
that are the most hazardous. Leaks of crude oil are generally less dangerous than
leaks of refined petroleum products, such as gasoline, which can cause explo-
sions, fires and contamination of ground water. Sour gas, which is natural gas
containing a relatively high content of sulfur is particularly hazardous because it
may contain high levels of hydrogen sulfide, a toxic gas.
Large power stations can convert coal, oil, and, to a lesser extent, natural gas
into electricity with fewer incomplete combustion products than can individual fires.

The production of wastes at these plants can also be regulated, and they tend to
concentrate the ash and waste products, minimizing the impact of such products
on the local environment. However, without sufficient pollution control systems,
large coal-burning power stations can be some of the most polluting point sources
in an area. In Central and Eastern Europe, China and India, for example, the use
of coal contributes considerable air pollution, especially SO 2 and particulates; with
the use of clean coal technologies, emissions of SO 2 and particulates can be reduced
as much as 99% (WRI, 1998). In the Czech Republic, for example, SO 2 emissions
were reduced by 36 0% and dust and particulate emissions by 49% (Havlicek, 1997).

Additional problems are created when this pollution becomes transhoundary pol-
lution. Large urban centers located along borders are problems not only for the
country in which the city is situated but also for their neighbors. The major in-
direct health effects of the pollution created by energy sources are global warm-
ing and acid rain. These are discussed in Chapter 11.
Pollution Prevention Strategies
Mitigation technologies already exist that can greatly reduce the emission of air -
borne pollutants at the source. Fitting power plants with scrubbers can reduce
sulfur dioxide emissions by up to 95%. Similarly, electrostatic precipitators and
bag filters can trap large amounts of particulate (dust, ash, soot, and hydrocar-
bons) in factory or power exhaust gases. What is possibly more important is that
new technologies have been developed, such as fluidized-bed combustion, which
are capable of burning raw or processed fuels much more efficiently than ever
before, greatly reducing polluting emissions. Additionally, more countries are de-
veloping cogeneration plants, which produce both heat and electricity for entire
cities. In countries such as India and China, natural gas—fired turbines, which are
less expensive and more efficient and have fewer emissions than conventional
coal-fired power plants, are showing great promise for electricity generation (WRI,
1994). Such improvement in efficiency of energy use not only mitigates air pol-
lution but also conserves resources of nonrenewable fossil fuels (WHO, 1992d).
HYDROPOWER
Use of Hydroelectric Power

For many countries, hydropower is emerging as the favored alternative to fossil
fuels. Hydroelectric power accounts for about one-quarter of the world's elec-
tricity output. Hydropower has been used extensively in developed countries and
developing countries alike. Europe uses about 36% of its potential hydroelectric
power, while North America has developed 59% of its potential. The potential
for developing countries to harness hydroelectric power is vast. Some investiga-
tors estimate that Asia, for example, has harnessed only about 9% of its poten-
tial; Latin America, 8%; and Africa, 50/) (WHO, 1992d).
Hydroelectricity is a renewable source of energy and is relatively clean, ac-
cording to its proponents. It must be noted, however, that due to siltation, the

life expectancy of a hydroelectric dam is generally measured in decades, rather
than centuries. Hydropower is generated by the construction of large dams over
fast-moving water, connected to generators. For a country to be able to consider
constructing these dams, it must have suitable water resources and it must also
have a large amount of money, as these systems are tremendously expensive.
There are several serious and significant problems associated with these darns.
For the investment in them to be financially viable, the dams must be very large,
flooding huge areas of land. This can cause an array of problems in the local en-
vironment. For example, when dams fail, although this is rare, they may cause
catastrophic flooding and loss of life. Large darns are suspected of causing small
earthquakes in some regions prone to earth movement. An ambitious project to
build large darns in northern Canada was recently suspended when it was real-
ized that huge tracts of forest (as large as some European countries) would be
submerged. Entire ecosystems may be drowned in this way, and residents in the
area to be flooded may be displaced at great cost.
Direct Effects on Health

The actual building of the dams can he hazardous to the workers. Over 10,000
skilled and unskilled workers are needed to construct a large dam, and accidents
and deaths constitute a significant occupational hazard. Additionally, after the
dam is built, the area flooded by (lammed water is usually significant, and dis-
placement of the local population can be a problem. For example, two recent
dams in India and Thailand displaced 20,000 and 30,000 people, respectively.
This displacement can cause psychological stress due to the loss of homes and
livelihood, and physical problems from the disruption of usual food supplies and
other life supports. Dams have been known to collapse, causing flooding of the
area downstream (WHO, 1992d).
On the positive side, hydropower prodtices large quantities of cheap electrical
energy at low cost (after construction of the dam). As with other sources of elec-
tricity, this fuel can then be used for refrigeration, health care, and other functions
that have a direct positive effect on human health. Also, the dammed water can
be used for irrigation purposes, as it has been in India and China, thus having a
direct positive effect on agricultural food production. Another positive feature is
the ability to breed fish in dams and improve the diet of local people. Of course,
the reservoirs behind all dams eventually silt up so a dam has a limited lifetime.

The actual process of generating hydroelectric power does not create wastes or
other by-products that are detrimental to human health. The accumulation of
water necessary to produce this electricity, though, can change the entire bio-
logic local environment. For example, the Aswan dam in Egypt contributed to
the spread of the parasitic disease schistosomiasis in the river and irrigation sys-
tems in the Nile basin. Shallow waters at the edges of the new lake aided in the
rapid growth of freshwater snails, the vector for schistosomiasis. As was described
in Chapter 3, the lower Seyhan irrigation project in Turkey is an example of how
malaria was introduced into an area where it was not previously endemic by the
building of a hydroelectric dam. Again, the vector for malaria, the mosquito, grew

rapidly because of the new, almost stagnant, water supply. Other organisms, e.g.,
algae and midges, may also flourish. Down river, the land is deprived of water,
esscntial for humans and agriculture.
Aquifers downstream are also affected. A hydroelectric dam essentially
changes completely the physical environments above and below its structure, and
hence changes the lives of the people in those environments. This change often
has a negative effect on those living close by. Because large reservoirs are often
built in remote areas however, the health impacts of hydroelectric dams have
been thought to have only minor effects in many countries (WHO, 1992d).
Another indirect effect can be increased mercury exposure from fish, when
the dam creates conditions by which mercury in flooded soils and vegetation ac-
cumulates in fish eventually consumed by local people. This has been a particu-
lar problem in Canada (JBMC, 1995).
Electricity These possible risks associated with the use of electricity are, of course,
independent of the way in which the electricity is generated. Electricity is dis-
tributed at high voltage to communities and then stepped down in voltage be-
fore delivery to homes. The transformers that convert voltage used PCBs in the
past and were a source of heavy exposure for workers. Now, the PCB5 have been
replaced with mineral oils in most countries. Wiring and appliances must be safety
designed and maintained to prevent injury from shock or damage from fires.
An additional concern is that a number of studies have linked electromagnetic
fields from the power lines that carry the electricity that is generated, to a num-
ber of different types of cancer. These studies have been under recent scrutiny,
however, as some researchers question their methodology and conclusions.
Mitigation by Environmental Management

Most of the direct effects on health can be prevented or mitigated by adopting ap-
propriate environmental management practices in the construction and operational
stages of the darn. If safety factors are not considered in the construction of large
dams, it is usually a result of financial constraints or poor planning (WHO, 1992d).
Mitigation factors to reduce the risk of schistosomiasis and mosquito-borne diseases
include clearance and leveling; water table and shoreline management practices to
discourage the breeding of invertebrate carriers; planning of settlements; the pro-
vision of water supply and sanitation to diminish people's contact with infected wa-
ter to vectors; chemical (i.e., mostly using pesticides) or integrated pest control (i.e.,
depending icss on pesticides and more on environmental management and biolog-
ical control); and vaccination and other public health practices as required. Health
education and the promotion of public participation in the reduction of hazards are
of the utmost importance. None of these measures will be effective unless the im-
pacts have been defined at an early stage and nmnitoring instituted to guide miti-
gation activities. The WHO/FAO/UNEP/UNCHS Panel of Experts on Environmen-
tal Management for Vector Control (PEEM) has developed a number of guidelines
and training materials to assist planners and engineers in undertaking these tasks
along with representatives from the health sector. Indirect negative health effects
asscciated with the displaced population are more difficult to mitigate and require
imaginative project planning (WHO, 1992d).

Environmental impact assessments (as discussed in Chapter 3) should be done
on any new project. There has been enough information from previous con-
structions to be able to predict some of the possible environmental changes that
will occur from the dam and its subsequent lake. Small-scale projects have the
advantage of offering smaller setup and operational costs, while having less of
an impact on the local environment (WHO, 1992d).
NUCLEAR PoWER
Use of Nuclear Power

Electrical power generation by nuclear reactors has been growing steadily over
the last three decades. By the end of 1989, there were 436 power electricity gen-
erating reactors in the world, spread around 26 countries, with a total capacity
of 320 gigawatts (approximately 17% of the global electricity production).
The nuclear resources for the production of energy by nuclear fission are ura-
nium and thorium. Uranium production has remained at a fairly constant level
of approximately 37 thousand tons per year. Low-cost uranium resources exist
in Australia, Canada, South Africa, Nigeria, the United States, and the countries
of the former Soviet Union. The geographical distribution of nuclear reactors is
not uniform throughout the world; about 95% of the total generating capacity
is concentrated in North America, Europe, and Japan.
Currently nuclear power is based on the process of fission, the splitting of
uranium atoms. Nuclear energy consumes small amounts of fuel and is poten-
tially a very cheap and pliable source of energy. However, several widely pub-
licized incidents in the 1970s (such as Three Mile Island in the United States)
and 1980s (such as Chernobyl in what was then the Soviet Union) have caused
grave concern over the ultimate safety of this form of energy. Three-Mile Is-
land (TMI) and Chernobyl are the only two recorded incidents in which the
effects of an accident in a nuclear power plant were known to have created
measurable off-site consequences. While both accidents appeared to have been
the result of a combination of design shortcomings and operator error, off-site
releases of radionuclides were many orders of magnitude lower in TMI than
those from Chernobyl.
At TMI, the core heated and melted, but the pressure vessel and containment
structure remained intact. At Chernobyl, the reactor was an obsolete design and
was not operated properly. Impn per experimentation and operator error provoked
a surge in reactor power that could not be controlled, leading to a rapid rise in
temperature, explosion of the core, and an intense fire. This accident resulted in
the death of 31 emergency workers, the contamination of large areas of the Eu-
ropean part of what was then the Soviet Union, and about 1000 thyroid cancers
in children so far (WHO, 1995c). In addition, several million people are living in
contaminated areas and 100,000 people have been permanently evacuated from
a 30-kilometer exclusion zone around the reactor. The Chernobyl reactors have
been shut down, although they continue to supply about 10% of the power for
Ukrania as late as 2000. Because of safety concerns, many utilities in developed
countries have been forced to abandon plans for new reactors. In some countries,

including Germany, Sweden, and Canada there has been pressure to close reac-
tors that have already been built and are functioning normally.
It is generally acknowledged that the normal operation of nuclear power plants
produces less environmental pollution than many other fuel cycles. Electricity gen-
eration in the nuclear fuel cycle does not produce sulfur dioxide, oxides of nitro-
gen, particulates, carbon dioxide, or other greenhouse gases. However, in a com-
prehensive picture of the hazards, the entire nuclear fuel cycle should be considered.
This includes mining and milling of uranium ore, fuel enrichment and fabrication,
reactor operation, spent fuel storage and transport, fuel reprocessing, and finally,
the disposal of radioactive waste and decommissioning. The health hazards specific
to the nuclear fuel cycle are those due to exposure to ionizing radiation (includ-
ing radon). An explanation of radioactivity and radiation was provided in Chap-
ter 2. Other hazards, such as exposure to toxic chemicals and dust that occur in
other fuel cycles, are also present on a limited scale. These are encountered mainly
in stages of the nuclear fuel cycle, fuel fabrication, and fuel reprocessing.
Fusion
An alternative nuclear technology to fission is called fusion, in which strong pres-
sures force together hydrogen atoms to release energy. Fusion-based nuclear en-
ergy would produce more energy with less risk but the engineering problems are
formidable. It is under development in a massive engineering program in the
United States along with several smaller projects in the United States, Japan, and
Europe. If successful, fusion energy could produce enormous quantities of cheap
energy from sea water, but the development costs and engineering obstacles make
this a distant possibility, not a likely short-term solution.
Stochastic (Non- Threshold) Effects

Generally, radiation effects can be separated into two sections: health effects that
are non-threshold, called by health physicists stochastic effects, and health effects
that have a threshold, referred to by health physicists as deterministic effects (see
Chapter 2, Physical Hazards) Cancer and hereditary effects are classified as sto-
chastic effects. The basic question in assessing risks for workers and members of
the public, from the routine operation of the nuclear fuel cycle, concerns the na-
ture of the dose—response relationship at low doses and dose rates (see Chapter
3 for information on dose—response curves).
Direct epidemiological evidence of occupational radiation health hazards
comes from studies of uranium mining and operation of nuclear installations
(WHO, 1992d). Uranium mining has been shown unequivocally to produce an
increase in respiratory cancer mortality (Howe et al., 1986; Howe et al., 1987;
Kusiak et al., 1993), in addition to the increase in the prevalence of silicosis
among the miners that contributes to the risk (Royal Commission, 1976).
As discussed by the WHO (1992d), epidemiological studies provide conflict-
ing evidence of radiation effects in populations residing close to nuclear facilities.
An increase in childhood leukemia was reported around two nuclear installa-
tions involved in reprocessing nuclear fuel in the United Kingdom. However,
other studies, such as those conducted in France around six nuclear installations,
did not reveal an increase in leukemia or cancer. A comprehensive study in the

United States examined cancer mortality rates around all 62 nuclear facilities in
the country and no increase in cancer mortality was noted. The WHO noted,
however (WHO, 1992d) that the U.S. studies included large areas and large pop-
ulations, so small increases in cancers would be hidden.
Deterministic (Threshold) Effects

Deterministic effects are those that are only seen after an acute exposure to high
doses of radiation that exceed some threshold. They include skin burns, damage
to bone marrow, and sterility. Such exposures have occurred in survivors of the
atomic bomb explosions in Japan and in a few workers in Chernobyl (see WHO,
1995c). Exposures of this magnitude are rare and occur only in occupational set-
tings or after serious nuclear accidents (WHO, 1994b).
Safety Approaches
The United States was one of the first countries to commit to a large-scale pro-
gram of nuclear power. The costs of building in safeguards and the difficulty in
insuring the facilities have essentially stopped the building of new reactors in that
country. While these facilities attracted strenuous public opposition, proponents
of nuclear energy point out that past problems have been problems of reactor
design and that newer nTlOdels are much safer. However, the extent of public
concern in many countries makes it unlikely that fission nuclear power will ever
become as widespread as its proponents originally hoped.
As a result of the Chernobyl accident, attention has been focused on the safety
of operating older types of reactors. Considerable effort is currently being un-
dertaken to backfit older operating reactors to achieve safety levels compatible
with current international standards. Mitigation strategies for nuclear power
plants focus on prevention, i.e., building safer reactors. These built-in safety fac-
tors include barriers to prevent releases, backup systems for system failures, and
quality assurance.
Another major debate concerns radioactive waste. Different stages of the nu-
clear fuel cycle produce radioactive wastes. At present, there are two approaches
to the management of irradiated reactor fuel. These are the temporary or per -
manent storage of spent fuel and the reprocessing of spent fuel. The latter en-
tails the subsequent recycling of uranium in thermal reactors (WHO, 1992d).
Ccnsiderations for radioactive waste disposal can be divided as follows.
Low- and Intermediate-Level Waste Disposal Safe methods for the management
and disposal of low- and intermediate-level wastes arc well established and op-
erational. Essentially safe disposal is ensured by the establishment of effective
barriers, preventing significant transfer of radionuclides into the environmental
pathways that might lead to excessive human exposures. Typical disposal strate-
gies involve shallow-ground disposal with or without a concrete liner, near-sur-
face engineered structures, or an underground rock cavity repository. Doses to
the general public from such waste disposal are likely to be extremely low.
High-Level Waste Disposal High-level radioactive waste is characterized by heat

generation and a long half-life. Many of the high-level wastes are produced by re-

processing nuclear fuel and are often in liquid form. Because of the heat generated,
these liquid wastes are often stored for a year or more in water tanks to cool th)wn
before being processed for ultimate disposal. Once excessive heat generation has
subsided, liqtud waste is usually solidified prior to disposal. Spent fuel elements dis-
posed of without processing are also classified as high-level wastes. These wastes
need to be deposited in deep underground, stable rock formations with multiple
engineered barriers to prevent their leakage into the environment. The integrity of
these structures must be such that there are no predictable and unacceptable fu-
ture risks for human health or the environment over a period of thousands of years.
ALTERNATIVE_ENERGY SOURCES
A number of energy sources have been developed as alternatives to the previously
mentioned sources. The most promising ones include wind, solar, and geo-thermal
power. These particular alternatives, are promising because they are generally re-
newable. They are generally thought to be prohibitively expensive, although as
shown in Box 9.2, this need not necessarily he the case. Nonetheless, these sources
will not be viable global energy sources for many years to come and still cause
health-related problems (see Table 9.6). One of the major problems with solar-
derived energy is that the generating facilities are individually small and too decen-
tralized for an effective power grid. However, they can be a very useful local power
source, meeting local needs relatively cost-effectively, as noted in Box 9.2.
As with any energy source, there are also disadvantages to these technolo-
gies. Not all countries have the necessary environmental conditions for their im-
BOX 9.2
The Potential for Cost-Effective Electricity from
Alternative Energy Sources
Considerable gains in the use of alternative energy sources have been made, despite
the lack of commitment on the part of energy planners, technical failures attribut-
able to poor capacity for local maintenance, and the high costs associated with these
new technologies. Field experience and technical developments widened the appli-
cation of wind turbines and solar photovahaic (PV) arrays in developing countries.
These are already cost-effective at many remote sites (Foley, 1992). (Several case
examples are provided in World Resources 1994-1995 [WRI, 1994].) As shown in Fig-
ure 9.6, the price of wind energy dropped by two-thirds over the last decade, and
some 20,000 electricity-generating wind turbines, as well as large number of wind-
powered water pumps, have been installed worldwide (WRI, 1994).
Solar power has also become more cost-effective. The detnand for PV assemblies
is growing steadily, and prices are expected to fall further. Smaller solar applica-
tions, including water heaters, cookers, kilns, and crop dryers, have been success-
ful in India and China.

TABLE 9.6
SUMMARY OF SIGNIFICANT HEALTH EFFECTS OF TECHNOLOGIES FOR
GENERATING ELECTRICITY
Technology Occupational Health Effects Public Health Effects
Geothermal Exposure to toxic gases routine Disease from exposure to toxic brines
and accidental and hydrogen sulfide
Stress from noise Cancer from exposure to radon
Trauma from drilling accidents Arsenic poisoning from contaminated water
Mercury poisoning via fish in this water
Hydropower Trauma from dam failures Mercury poisoning through niercury
Trauma from construction accidents contamination of water and fish
Disease from exposure to pathogens Malaria spread to new areas
Health effects from lifestyle Schistosomiasis
disruption associated with forced
relocation
Photovoltaics Exposure to toxic materials during Exposure to toxic materials during
fabrication, routine and accidental fabrication and disposal, routine and
accidental
Wind Trauma from accidents during Noise disturbance
construction and operation
Solar thermal Trauma from accidents during
fabrication
Exposure to toxic chemicals during
operation
plementation. Both wind and solar power are considered to be very environ-
mentally friendly, but the use of geothermal power (tapping into the earth's core)
requires pollution control measures for the release of hot, mineral-filled under-
ground water to avoid a negative environmental impact, including mercury con-
tamination of fish, arsenic contamination of drinking water, and the effects of
heated water on ecosystems.
0.3
0.25
0.2
j
75
o9:5
- Percent
6 Percent - -
0.05
Figure 9.6 Cost of electricity

frorn wind energy at two inter- 0
est rates, 1985-94. From WRI, 1985 1987 1989 1991 1993
1994, with permission. Year

The most readily available option in many places is simply to encourage the
natural movement of developing countries up the so-called energy ladder. The
"ladder" is a ranking of fuels from most polluting to least. This process of climb-
ing the ladder has taken many countries from the relatively dirty solid fuels to
the higher-quality fuels - gas and electricity. Generally, communities will move
up the ladder if fuel is available and affordable. In some areas of the world, the
regular supply of alternative fuels is the problem rather than the cost.
COMPZ\RTNG RTSIKc
Throughout the 1970s and 1980s, comparisons of risk from different energy
sources were investigated. However, these comparisons tended to account short-
term local health and environmental effects only and discount the more diffi-
cult-to-measure effects, such as the effect of increased CO 2 emissions, which could
have global implications. It is also difficult to account for all the health risks that
occur across the energy production cycle and to all stakeholders involved.
Unquestionably, reducing fossil fuel consumption will require raising the price
of these fuels. Electricity, natural gas and coal are subsidized in most countries;
petroleum consumption is subsidized in oil-exporting developing countries (WRI,
1998). The recognition that energy, like water, is a vital resource, underlies these
policies. Refrigeration, for example, saves lives from foodborne illness. If prices
are changed, the immediate benefits must be weighed against the risks.
The perception of the risk associated with a source of energy is usually more
important in the minds of decision makers than the actual risk. A nuclear power
station is more likely to be perceived as posing a higher risk than a more com-
mon source of energy, e.g., biomass fuels, even though the former has actually
caused less mortality than the latter. The factors influencing the perception of
risk were discussed in Chapter 4. The subjective perceptions of the risks involved
with any given energy source must be taken into account by all those involved.
PRIORITIES FOR ACTION

In 1992, a panel from the WHO Commission on Health and Environment (WHO,
1 992d) prepared a report on what they considered to be priority concerns re-
garding energy. The energy-related issues 'of the highest immediate and/or fu-
ture concern for environmental health" were the following:
• exposure to noxious agents in the course of domestic utilization of biomass

and coal
• exposure resulting from urban air pollution in numerous large cities of the
world
• energy-related climate changes
• serious energy-related accidents with environmental impact.
The first two problems "involve very large groups of people (hundreds of mil-
lions) of all ages, mostly, but not exclusively, in developing countries, who are
exposed to significant health hazards requiring intensive mitigating action, now."

Health-related problems associated with biomass fuel were discussed above; ur-
ban air pollution was discussed in Chapter 5. Climate changes (the greenhouse
effect) will he discussed in Chapter II. Accident-related injuries have been dis-
cussed throughout this book.
The indoor use of biomass fuels, with their incomplete combustion, affects
large numbers of people in developing countries (actual numbers would be dif -
ficult to estimate). Many obstacles exist to changing this major health threat,
such as the need to convince local people that it is a threat, the low position
women have in many societies (women and children are often the most affected
by this indoor air pollution), and economic considerations. Improving smoke
stacks, changing fuels, and increasing ventilation are all seemingly simple mea-
sures but difficult to apply in practice. Education of the at-risk groups in an ap-
propriate cultural milieu is likely the most important and feasible strategy to over-
come this problem.
The major causes of urban air pollution are overwhelmingly related to en-
ergy use: production of electric power, transportation (cars, buses, and trucks),
home cooking and heating (particularly if coal or biornass is used), and local in-
dustry. Global assessments of air pollution have found that well over one-half of
the 50 cities throughout the world that they surveyed had higher levels than
WHO guideline values (see Chapter 5). This has been estimated to affect ap-
proximately one billion people. One of the major difficulties with air pollution
control is its high cost. Changing from one fuel source to a cleaner one is ex-
pensive, and sometimes the benefits of changing are not immediately seen by in-
dustry or gcvernmdnts. Developing countries often cannot afford to import
cleaner fuels and therefore rely on domestic coal or biomass.
Climate change is another urgent matter for a different reason (see Chapter
11). Climate change resulting from the use of fossil fuels might he irreversible,
and could be devastating.
Severe accidents could occur, with significant adverse health effects in many
energy technologies. A comprehensive record of the major accidents in the this
field was published in 1990 by the United Kingdom Watt Committee on Energy
(WCE, 1990). National strategies must be created to ensure proper maintenance,
disaster planning, and data collection.
udtiw
What energy sources are used most heavily in your home town?
What do you know about the hazards associated with them?
Are there alternatives that should be promoted?
What issues/difficulties can you think of in your country concerning the
control of the energy-related factors listed above?
You are the environmental health officer on duty. You receive a call that
there has been a small spill of irradiated water from the nuclear power plant. Us-
ing the approach outlined in Chapters 3 and 4, describe the steps you would take
to address this problem.

10
INDUSTRIAL POLLUTION AND
CHEMICAL SAFETY
LEARNING OBJECTIVES

• describe the scope, dimensions, and trends in industrial pollution, includ-
ing knowledge of the nature of major industrial processes or events that
have had significant environmental health consequences
• indicate the scope, dimensions, and trends in occupational diseases
• discuss approaches to managing occupational and environmental health
problems
• discuss the issues related to industrial waste management
('14APTFR CflNTPr'JTS
Extent of Industrial Pollution The Social Context of Occupational

Public Exposure from Industrial Sources Health and Safety
Industrial Air Pollution The Internal Responsibility System
Industrial Water Pollution Workers' Compensation
Hazardous Waste and Chemical Women in the Workplace
Contamination Dimensions and Types of Occupational
Hazards by Industry Health Problems
Materials Extraction Occupational Chemical Hazards
Processing Industries Physical Hazards
Manufactu ring Mechanical Hazards
Service Industries Biological Hazards
Psychological Hazards
Major Chemical Contaminants of
Concern in the General Environment Industrial Environmental Accidents
and the Workplace Approaches to Prevention
Toxic Metals Applying a Prevention Framework
Solvents Occupational Exposure Standards
Bulk Raw Materials
Chemical Poisoning in
the Community
332
FXTFNT OF TNDTTTRTAJ POT JTTTTON
Industrial pollution has grown to be a problem of global proportions, serious

enough to pose an immediate health hazard in some areas and a limit to future
economic growth. The pollution emissions and resource requirements of indus-
try are substantial, as shown in Box 10.1.
Industrial development is essential to combat poverty and improve the qual-
ity of life. Such development may lead to serious environmental pollution and
occupational health hazards, however. Measures must be taken to prevent the
health problems associated with industrial in development to avoid the kinds of
social and environmental destruction that occurred during the Industrial Revolu-
tion in Europe in the late eighteenth and nineteenth centuries (see Chapter 1).
Only a few industrial sectors are responsible for most raw material con-
sumption and most pollution. These include food and agricultural processing,
metal extraction and processing cement works, the pulp and paper industry, oil
refining, and the chemical industry.
The degree to which development can be sustained is highly dependent on
the following factors: the technology adopted; the enactment, enforcement of,
and compliance with regulations and international treaties; the infrastructure;
and the volume of production, which is in turn related to the market being sup-
plied; population; dependence on exports and the stability of markets; the dis-
tribution of income, and standards of living. In short, industrial pollution is in-
extricably linked to economic development, but in ways that are complicated and
difficult to separate, as discussed in Chapter 1.
PITRTJC FXPOSTJRF FROM INf)IJSTRTAJ SOTTRC.F.S
Industrial Air Pollution

As discussed in Chapter 5, air pollution is an unintended but direct consequence
of economic activity. It is generated by transportation, power production, home
heating and cooking, and industrial production. Some of the costs of air pollu-
tion are shouldered by the industry that may be responsible, in the form of higher
costs of production, for pollution control and poor public relations. Much of the
cost of pollution control is passed through as higher prices for goods and services
to offset costs. However, the cost of the effects of pollution are not accounted for
and may be considerably greater. The public bears most of the costs of air pol-
lution: human health problems, destruction of materials, plant and animal dam-
age, poor visibility, loss of appeal for tourists, and reduced quality of life for res-
idents. As many of these costs are not obvious, they are not charged back to the
industry that may be responsible. This means that the community subsidizes, or
indirectly pays for, the cost of the industry to do business.
The effects of air pollution can be minimized by siting industry away from
residential communities or places, such as river valleys, where air pollution can
accumulate. The most effective approach to reducing air pollution is usually to
control its emission at the source, through a variety of measures that reduce the
amount of pollution released to the atmosphere. Industry that is energy-efficient
INDUSTRIAL POLLUTION AND CHEMICAL SAFETY 333

BOX 101
Industrial Pollution Emissions and Resource Requirements as

Proportion of Overall Emissions and Resource Requirements
In the countries of the Organization for Economic Cooperation and Development

(OECD), industrial output represents around one-third of the aggregate gross na-
tional product (GNP). The pollution emissions or resource requirements of industry
in 1987 were the following:
15% of water consumption (excluding water used for cooling)

25% of nitrogen oxide emissions
36% of final energy use
40%-50% of sulfur oxide emissions
SO% of contributions to the greenhouse effect
60% of biological oxygen demand and substances in suspension
75% of noninert waste (infectious, toxic, or radioactive waste)
90% of toxic substances discharged into water.
Source. OECD, 1991.
or that uses less polluting technologies may produce less air pollution. This may
involve increasing the efficiency of combustion, physically trapping particles be-
fore they go into the smokestack, and chemically trapping or scrubbing airborne
emissions before they are released into the atmosphere. Much industrial air pol-
lution comes from combustion of coal, oil, or gas. The specific pollution, there-
fore, often includes particulate matter and sulfur dioxide (SO7). In addition, mans'
industries emit other specific toxic subslances and odcrs, as discussed in the sec-
tion Hazards by Industry below.
One of the most effective ways of controlling air pollution at the local level
has been to build higher smokestacks at stationary sources (see Chapter 5). De-
pending on the stack height and the temperature of the emissions, the emissions
from the source rise higher in the atmosphere, travel further, become more highly
diluted in the atmosphere, and are less likely to affect the local community. The
problem with this strategy is that it sends air pollution long distances away from
the source. Air movements high in the atmosphere can transport air pollution
long distances, allowing the pollutants to fall with rain or snow at locations far
away from the source. This is to he one of the more important causes of acid de-
position, which has become a problem in recent years (see Chapter 11).
Despite these problems, air quality has improved in many cities of the world
(see Chapter 8) and serious air pollution crises, such as occurred in London in
the 1950s, are much less common today. However, the control of air pollution
is difficult and expensive. It is especially difficult in plants that have not been
properly designed in the first place, such as older plants. The cost of air pollu-

lion control increases greatly with the degree of control. The cost of reducing
emissions by 95% to 99% and then to 99.9%, for example, can be just as ex-
pensive as the first 95% reduction. Maintenance of the plant and regular testing
of air pollution control devices is critical to ensure that they work properly.
Industrial Water Pollution

As was discussed in Chapter 6, water pollution occurs as the result of the release
of a pollutant into a body of waler such as a river, lake, or ocean. Much indus-
trial water pollution affects the quality of the water and the biota in the waler
without having direct effects on human health, as is the case for lignin and Wood
waste from the pulp and paper industry.
Some pollutants, mostly organic chemicals, will eventually break down as a
result of bacterial acticn and other processes in the soil and water. This process
of natural disposal and recycling is called biodegradation. Others that are not so
easily degraded will persist in soil and sediment. Because bodies of water are
home to many microorganisms and invertebrate species, the pollutants are often
taken up in the bodies of these species. This is called bioaccuinulation. Those pol-
lutants that persist in the environment and are not easily degraded biologically
tend to accumulate in these species and are concentrated in the bodies of other
species that feed on them, such as fish. Likewise, other forms of wildlife, such as
bigger fish and mammals, may further accumulate these pollutants. This is called
bioconcentration or biomagnificarion because at each level the amount of pollutant
becomes more highly concentrated in the animal's body. This is illustrated in Fig-
ure 1 0.1, which shows the bioaccumulation and biomagnification of polychlo-
ride biphenyls (PCBs) in the Canadian Great Lakes aquatic food chain.
j rring gull eggs

124 ppm
4tQ~
'__C_ Lake trout
4.83 ppm
Rainbow smelt
1.84 ppm
Zooplankton
0.123 ppm
Phytoplankton
0.0025 ppm
Figure 10.1 Bioaccumulation and hiomagniticatiori of PCBs in the Canadian Great Lakes
aquatic food chain. From Environment Canada, 1987, with permission.

Hazardous Waste and Chemical Contamination
As noted in Chapter 2, hazardous substances are compounds and mixtures that
pose a threat to health and property because of their toxicity, flammability, ex-
plosive potential, radiation, or other dangerous properties. Although hazardous
substances may be released to the environment during transportation, in the pro-
duction of goods, during maintenance in service operations and as occupational
hazards, their principal impact on the environment comes from the dispersal of
waste, after the material has been used or produced as an unwanted by-product.
The storage of large amounts of liquids also creates a risk of continuous smaller
leakages of toxic chemicals. These may end up in the ground or local waterways.
Many flammable liquids are lighter than water and are quite volatile, meaning
that these liquids will seep down to the top layer of the groundwater and from
there, the emerging fumes will seep up thr ugh the ground, possibly a long dis-
tance from where the leakage occurred. To prevent spillage and leakage from
reaching the environment, tanks with these types of bulk materials should have
walls around them that can contain the spillage (called berms or blinds) and the
ground under the tanks should be provided with drainage that channels the
spilled materials into safe storage.
Hazardous waste is not a new threat to health. Exposure to potentially dan-
gerous chemicals has occurred in the smelting of metals and tanning of hides
since ancient times; hydraulic mining released heavy metal into groundwater
during the nineteenth century; and in the early days of industrialization, urban
areas were saturated with pollution, including chemical wastes. Today, however,
the problem has assumed much greater urgency as the result of the factors dis-
cussed below.
• The number and hazardous nature of toxic substances in common use has
changed dramatically. Since World War II, research and development in or-
ganic chemistry and chemical engineering have introduced thousands of new
compounds into widespread commercial use, including such persistent com-
pounds as the PCBs and more potent pesticides, accelerators, and plasticizers
with unusual and poorly understood effects. Compounds for which there has
been little time to evaluate are in common use today.
• The production of chemicals has risen dramatically. In 1941 production of all
synthetic organic compounds in the United States alone was less than one mil-
lion tons; since then it has increased 100-fold. Many of these substances are
toxic and degrade very slowly, resulting in accumulation in the environment.
The environment contains much greater quantities of these toxic chemicals
than ever before.
• Toxic chemicals are much more intrusive in daily life. Many chemical plants
or disposal sites that were once isolated or on the edge of town have become
incorporated into urban areas by suburban growth. Communities now lie in
closer proximity to the problem than they have in the past. Some communi-
ties are built directly over old disposal sites.
People come into contact with tcxic substances in many ways. Exposure may
occur at several points in the life cycle of the substance. Some people work in

plants that use chemical substances in an industrial prcccss and are not able to
change clothes or wash before coming home due to lack of shower facilities.
Some people are exposed to chemical substances in household products (e.g.,
cleaning agents, paints, carpet glues). Sometimes exposure occurs inadvertently,
for example, to pesticide spraying or environmental tobacco smoke (previously
called second-hand smoke). Still others may reside near hazardous waste disposal
sites that are illegal or poorly designed, or that provide opportunities for expo-
sure as a result of accidents, careless handling, lack of containment of the sub-
stance, or lack of fencing to keep children off the site.
Public attention tends to focus on carcinogens, pesticides, and radiation haz-
ards. However, innumerable compounds that do not fall into these categories can
pose a threat to the public's safety and health. Some people appear to react to
even very small exposures to chemicals, experiencing what has been called mul-
tiple chemical sensitivity. (MCS) described further in Box 10.2.
Although we are concentrating here on toxic exposures, we should not for-
get the substantial problems of safety that appear in many situations. Gasoline,
for example, can explode with the destructive force of gunpowder. Fires and ex-
plosions also generate their own toxic hazards, depending on the chemicals that
were initially present.
Despite the fact that incidents involving hazardous substances take many
forms and may be highly individual, the great majority of incidents involving
toxic wastes especially seem to involve a relatively narrow range of hazardous
substances, which include solvents, paints and coatings, metals, PCBs, pesticides,
and acids and alkalis. Solvents, particularly chlorinated compounds, are envi-
ronmentally persistent, meaning that they tend to remain in the ground or wa-
ter as contaminants for many years and are concentrated in the bodies of fish,
birds, and other wildlife. Many solvents are toxic to human beings in relatively
high concentrations and some are known or suspected carcinogens. In addition,
these compounds are usually of direct concern for their potential effects on biota
and ecosystems. The most toxic solvents have been withdrawn from industry for
some years but old waste sites may contain significant amounts of benzcne and
trichiorethylene. Some of these same compounds, stich as benzenc and toluene,
are also present as combustion products when organic material such as tires are
burned. Paints and coatings are of concern primarily because of the solvents and
metals they may contain.
Heavy metals are also environmentally persistent and may be highly toxic.
Although the chances of significant exposure occurring as a result of exposure
in a hazardous waste site are low, this cculd happen, especially to a young child
who is playing in contaminated dirt. Areas contaminated by smelter or lead bat-
tery reprocessing operations, where arsenic or lead in the soil may reach high
levels, pose a particular problem.
Chlorinated cyclic hydrocarbons, including dioxins, pen tachlorophenol, and
PCBs, are very damaging environmentally because they persist for long periods
and are consumed and accumulated by wildlife. These compounds are capable
of causing an unusual and persistent skin rash called chloracne that appears on
the face and neck of people who are heavily exposed. Some of these compounds
cause cancer and adverse reproductive effects in experimental animals. However,

BOX 10.2
Multiple Chemical Sensitivity
Multiple chemical sensitivity (MCS) is the common name for a set of symptoms that
occur in the setting of chemical exposure. These symptoms are often vague and
nonspecific and do not correspond to the known toxic effects of these chemicals.
The symptoms may include fatigue, confusion (called brain fog by some advocates,
loss of appetite, headache, and nausea. They may occur after the patient has expe-
rienced exposure to very low levels of a chenmical, well below the levels known to
cause toxic reactions. Sometimes they seem to occur at times when exposure is un-
likely but sufferers feel that they have been exposed. Some people believe that MCS
represents a generalized allergic reaction to all chemicals. The workings of the im-
mune system, however, are highly specific and one normally reacts only to partic-
ular chemicals or classes of chemicals. Sufferers of MCS often respond to chemicals
of many different types, regardless of chemical composition. The most common
chemicals that trigger this reaction seem to be perfumes, pesticides., solvents, to-
bacco smoke, and food additives. Research on the problem has resulted in many
theories, but little firm evidence for a mechanisni.
Patients with this disorder may come from all walks of life but most are female,
young, relatively affluent, and either work at home or work in office jobs. To de-
termine the cause of their syniptotns, they cornnionly consult practitioners of al-
ternative medicine, some of whom may give them the diagnosis of MCS. The effect
of the diagnosis of MCS on them is often quite dramatic. The diagnosis becomes a
central feature of their lives. They may withdraw from their usual daily life, quit
work, change their diet, change their housing, and require visitors to avoid bring-
ing any chemical into their surroundings, even freshly washed clothes. Many times
these changes are very radical and have the effect of isolating them from family,
friends, and society. Often they show features of depression or obsessive-compul-
sive behavior, although it is controversial whether this is a cause or a result of their
condition. Alternative treatments are long, involved, and costly, and there is no ev-
idence that they work. Because conventional medicine does not recognize the dis-
order, there is no obvious medical treatment. Psychotherapy seems to he the most
effective form of treatment available. Most patients refuse this, however, and many
react angrily to suggestions that their condition may have a psychosomatic dinien-
sion.
One of the problems in investigating MCS is that the definition and the terms
used change frequently. The leading advocates for the existence of MCS as a dis-
tinct clinical disorder once called themselves clinical ecologists, and now call them-
selves environmental medicine practitioners. In the past, MCS itself has gone by the
names of chemical sensitivity, twentieth-century disease, and environmental hype rsens itivity
disorder. Some of these practitioners believe that MCS covers a wide variety of seem-
ingly related illnesses, such as sick building syndrome (which occurs when people
working in a building with poor ventilation feel ill; see Chapter 8), chronic fatigue
syndrome (another nonspecific diagnosis possibly related to a viral infection), and
more conventional allergies and toxicity conditions. Most mainstream medical prac-
titioners strongly disagree that this entity has a distinct pathophysiological basis and
believe that a MCS-associated behavior pattern may represent a psychological dis-
turhance on the part of some patients. Some believe that what appears to be MCS
is actually a psychosomatic, behavioral response to chemicals in the environment.
Others, however, believe that there may be unknown toxicological or immunolog-
ical responses that underlie the response of some patients to chemicals at low 1ev-

(';lti,IUed)
els but that the responses are not yet understood by current scientific knowledge
and, in any case, need not be disabling.
There are many examples in the past of disorders that were once thought to be
particular diseases that are now considered psychological responses to stress. These
have included hysteria, neurasthenia, and catalepsy—all diagnoses now discarded
by the medical profession. (The term hysteria, comes frorn the Latin word for uterus.
It is pejorative to svomen because it implies that women are biologically prone to
be emotionally unstable, and thus the term should not be used.) Some physicians
feel that MCS, chronic fatigue syndrome, and multiple personality disorder are mod-
ern examples of this type of condition. Others feel that some of these patients may
well have disorders that medicine cannot yet explain. It is possible that in a few
years MCS will cease to be a commonly used medical term and that some cases now
called MCS will be found to reflect conventional allergies and tcxicities, some will
be clearly psychological in origin, and some will remain difficult to explain. Sparks
et al. (1994) have provided a useful case definition, and summarized the theories
of paihogenesis, diagnostic testing, treatment, and social consideration.
Source: Various summaries produced bt' the Association of Occupational
and Environmental Clinics; See also Sparks, 2000.
humans appear to he more resistant to the effects of these compounds than other
species. Even so, these are dangerous compounds to the environment and must
be controlled for ecological reasons. We still do not know many of their more
subtle effects on humans and it is only prudent that we minimize exposure to
humans as well.
Pesticides are particularly dangerous in hazardous waste, especially the rela-
tively toxic class known as the orqanophosphates. Fires involving pesticide storage
areas are a particularly dangerous situation, as the pesticides may be converted
into even more highly toxic combustion products and substantial amounts of en-
vironmentally damaging dioxins and furans may be generated.
Strong acids and strong alkali are commonly found at waste sites and are dan-
gerous if there is a possibility of direct contact or inhalation of fumes. They may
cause serious skin and eye burns on contact. Some acids may generate clouds of
fumes that may cause lung injury. If mixed together, the acids and alkali may
generate intense, possibly explosive heat and substantial dangerous fumes. Two
acids that are particularly dangemus are nitric acid and hydrofluoric acid. Nitric
acid releases nitrogen dioxide, which may cause pulmonary edema and bronchial
irritation. Hydrofluoric acid is used for etching in the electronics industry and is
exceedingly dangerous when inhaled or when it touches skin or mucous mem-
branes. On contact with skin or eyes, it causes deeply penetrating burns.
Cyanide is present in some situations, especially gold-plating solutions. In-
haled cyanide fumes from the solution are highly toxic. Cyanide can be released
by mixing the plating solution with a strong acid, such as those often found at
hazardous waste sites.
A major unresolved issue in municipal solid waste handling is contamination
by hazardous waste disposed of by accident or intent. This can be minimized by
diverting such disposal into a separate waste stream. Other means have been

used to control release of the remaining hazardous substances from a landfill site
not constructed to receive such materials, to keep the hazard minimal. Some
communities have organized periodic pickup drives for collecting household haz-
ardous wastes to prevent contamination of sanitary landfills. Well-designed haz-
ardous waste disposal facilities, using the best available technologies of recycling,
dehalogenation, and containment, are urgently needed.
"A7AR,Dc, BY INDUSTRY
This brief summary can only give a snapshot of the types of health hazards that
may be related to industry. Information about the specific health hazards and
preventive approaches for each industry can be found in publications of the In-
ternational Labor Office (ILO), particularly the ILO Encyclopedia of Occupational
Health and Safety (ILO, 1998), as well as documents from the United Nations En-
vironment Program (UNEP) Industry and Environment Office in Paris. A num-
ber of major occupational health hazards occur in each of these industries (see
section Dimensions and Types of Occupational Health Problems, below).
Materials Extraction
This type of industry is sometimes called primary industry and represents the first
step in the process of creating manufactured products. It includes mining for met-
als and minerals, coal and oil extraction, forestry, agriculture, and fishing. Out-
puts of this type of industry include ore or metal concentrate, coal, oil, sand,
wood, fibres (cotton, wool, hemp), grains, and fish. Issues related to the food and
agriculture industry are examined in Chapter 7. These primary industries can be
found in all countries, but as countries develop they usually tend to represent a
decreasing proportion of the overall economy.
The types of pollution and hazards related to the mining industry include dust
in air and water pollution from the processes that use water to transport, wash,
or concentrate the raw materials. Mines and quarries also create physical scars
in the local environment and can cause major emergency pollution risks when
tailings dams (accumulations of debris that trap water behind them) burst or over-
flow. Often processing plants for concentration or refining of metals arc located
together with the mine itself, and these plants can cause major sulfur dioxide or
metals pollution, as has happened in a number of places. The sulfur dioxide pol-
lution occurs because the ores of many metals contain large amounts of sulfur.
Special problems accompany uranium mining as radioactive compounds can be
released to the environment.
Coal extraction is similar to metal mining, except that the coal mines are of-
ten colocated with coal power plants, which emit large amounts of particulates
(dust), sulfur dioxide, and toxic metals included in the raw coal (see Chapter 9).
The amount of pollution will depend on the quality of the coal and pollution
control measures. Dramatic air pollution situations related to coal extraction ex-
ist, for instance, around coal mines in central Europe, India, and China. Oil ex-
traction involves direct surface oil pollution from spillages, as well as air pollu-
tion from the burning (flaring) of excess gas combined with oil or from power
stations or petrochemical industries colocated with the oil field.

Although forestry creates mainly physical damage to the natural environment,
it can create important health risks if deforestation leads to floods, landslides, or
polluted drinking-water sources (see Chapter 11). Other agricultural industries
also produce physical changes in the environment, the main threats to health
being the use of pesticides and fertilizers. Spraying of pesticides from airplanes
can create high exposures to local residents and intensive use of nitrogen fertil-
izers can pollute groundwater and lead to high nitrate levels in drinking water
from wells (see Chapter 7, Modern Intensive Farming Methcds). The latter is a
major problem in several European countries.
Processing Industries
Industries that process extracted raw materials into concentrated intermediate
products are potentially large sources of environmental impact because of the
scale and nature of their operations. The metals industries, including iron and
steel production, transform metal ores to metal ingots, sheets, and pipes, and can
generate considerable air, water, and land pollution. Some metals, such as lead
and cadmium, are very toxic, and many incidents of poisoning in populations
living around such industries have taken place. Particular problems occur in in-
dustries that recycle scrap metal products, as the content of the scrap is not al-
ways well known, and a mixture of toxic chemicals may be emitted to the air or
water. Lead has been a particular problem in this regard.
Petrochemical industries have already been mentioned. They process oil prod-
ucts into bulk raw materials for the production of plastics and chemicals. These
raw materials themselves, e.g., benzene, may be highly toxic. Sulfur dioxide is a
common pollutant, as most raw petroleum oil contains sulfur. These industries
involve major fire risks, and when a fire occurs, the smoke will contain a mix-
ture of very toxic chemicals. Depending on the wind direction and town plan-
ning, population groups may be highly exposed. In some countries, such as the
United States and Canada, industry has attempted to address these problems with
comprehensive voluntary risk management programs that include public con-
sultation.
The major pollution source in the processing of forestry products is the pulp
and paper industry. Large amounts of water are used to prepare the pulp and
process it into paper. The lignin (a natural glue that holds together wood fibers)
in the wood gets washed out with the water as well as the remains of various
chemicals used in the processing. This pollution can seriously affect the water
quality as measured by the biolQqical oxygen demand (BOD). The BOD is an in-
dicator of the amount of oxygen required to hiodegrade all the organic material
in water and is the fundamental measurement used to monitor water quality.
Mercury fungicides were used in the past to keep the paper pulp from growing
moldy. Some of these fungicides ended up in the wastewater and have caused
long-lasting pollution of lakes, particularly in Sweden. The sulfate and sulfide
processes in the paper pulp industry lead to air pollution of mercaptans and other
extremely smelly chemicals. Odor pollution is common, but is often more no-
ticed by people traveling past a plant than those living close to it all the time,
because the nose adapts to smells. Another problem in the forest industry is the
pesticide treatment of timber or wood products, often carried out under primi-

tive conditions in the forests. Land pollution and occupational hazards result from
the use of arsenic compounds and pentachlorophenol to make timber resistant
to insect attack.
The processing of plant fibers may lead to problems with dust, mainly in the
workplace. Byssinosis, for example, is a common occupational lung disease caused
by inhalation of cotton fibres in processing plants. The sugar cane industry and
other processing industries create major water pollution with the leftover mate-
rials and nutrients from the plants, which can damage drinking-water sources.
Many of these industries use the leftover plant materials as fuel in water-heating
systems, often with resulting severe smoke problems. In addition, these indus-
tries use pesticides and process pesticide-contaminated raw materials, which can
lead to pesticide pollution of water and land.
Food-processing industries, such as abattoirs and fish-processing plants, cause
problems mainly as a result of the organic materials in the large volumes of meat
or fish residue that may he discarded. The waterways receiving the pollution can
be affected by overnutrition, or eutrophication, as discussed in Chapter 6, and
high BOD. The affected waterways are also likely to serve as carriers of any in-
fectious bacteria or parasites that emerge from the slaughtered animals or fish.
Odor is also a problem.
Man ufactu ring

In this type of industry, often called secondary industry and common all over the
world, raw materials and prccessed materials are used to create various consumer
and industrial products. The largest plants are those that make automobiles, trains,
airplanes, ships, and machinery. Occupational hazards are often the main health
problems, but air and water pollution can develop in relation to processes that
use toxic chemicals. The section Major Chemical Contaminants of Concern in the
General Environment and the Workplace gives examples of the major chemical
hazards that can be found in the manufacturing industry. Another problem is the
storage and disposal of toxic wastes that are produced in manufacturing processes.
In the production of paper, one of the most hazardous processes has been the
chlorine-bleaching of paper to achieve a snow-white color. The presence of chlo-
rine and organic compounds has led to the formation of toxic chemicals in ef-
fluent from the plant into water, including dioxins and furans. These chemicals
have potentially serious environmental effects even though they are only pro-
duced in small quantities. They are also suspected to cause reproductive and car-
cinogenic effects in humans. Fortunately, new technologies in pulp and paper
manufacturing do not require chlorine and thus avoid this problem. In the past,
mercury has often been used as a catalyst in the production of chlorine. This
mercury further contributes to water pollution.
Textile production is a major industry in developing as well as developed
countries. Cotton, wool, and synthetic fibers (usually made from petroleum oil)
are used to weave fabrics that go into clothes and furniture. Again, the health
hazards are mainly occupational, although dying processes and other use of chem-
icals can lead to severe water pollution.
The production of chemicals carries a great potential for pollution as it requires
all of the feedstock chemicals used in raw materials, process chemicals used in the

reactions and processes, intermediary chemicals, and the final chemical products.
This industry has received considerable attention, particularly in conjunction with
serious emergencies, such as the Bhopal accident in India, where more than
200,000 people were poisoned from a cloud of rnethyl-isocyanate, an intermedi-
ary chemical in the production of pesticides (Dhara and Dhara, 1995).
Other manufacturing industries with special problems include the production
of electrical batteries (lead or cadmium pollution), electrical transformers (PCB
pollution), furniture (paint or solvent fumes), microelectronics (solvents, arsenic,
occupational health problems) and glass or ceramics products (lead pollution).
Manufacturing of food products involves the production of biological waste. An-
other sector that is not always classified as manufacturing but nonetheless is as-
sociated with environmental hazards is the building materials industry (e.g., ce-
ment, asbestos, glues, and paints).
More advanced or refined products of manufacturing, e.g., specialist electronic
products such as computers, printed materials, music cassettes, and toys, can in-
volve unusual chemical or physical hazards. Examples of this are found in the
rare metals and special solvents used in computer chip production and the lasers
used in etching patterns. As mentioned before, occupational hazards often pose
the greatest danger in these industries.
A further area of concern related to these special products and some manu-
factured consumer products is the hazards that may he associated with their use.
Malfunctioning or unsafe machines can cause injuries to the user, and improper
use of electrical equipment can cause electrocution. Electromagnetic radiation
from computer screens or portable phones has been suspected of inducing ad-
verse health impacts, but thus far it appears that the health risks may be low.
Paints on toys can cause poisoning in children. A system of consumer protection
legislation and monitoring functions has been established in many countries.
Countries with a weak system may face difficulties in consumer product safety
and in acceptance of their exports by other countries. Some countries have es-
tablished recognition programs for products that meet criteria for "environmen-
tal friendliness" to further encourage the reduction of health and ecological risks
(so-called green labeling or ceo-labeling).
Service Industries
An increasing proportion of overall economic activity is based on the provision
of services, in contrast to the production of goods. This is often referred to as ter-
tiary industry and includes restaurant and hotel services, health services, personal
services (such as hairdressing), entertainment, travel, tourism, public adminis-
trative services, telecommunications, and the new high-tech industries (such as
software production). Generally they do not produce much environmental pol-
lution, although all establishments at which large numbers of people are assem-
bled create increased pressures on sanitation and waste management, e.g., tourist
resorts create greater needs for sewage treatment. Hospitals and medical lahora-
tories have particular problems with medical waste, which can contain infectious
agents and radioactive materials.
Another issue related to concentrations of people is disturbing noise. The travel
and transportation industry causes a fair amount of noise around airports, mo-

torways, train tracks, and busy streets in urban areas. The increasing demand for
high speed has led to increasing noise pollution levels. In countries with high
population densities, such as The Netherlands or Japan, there is often not enough
room to provide for wide separation between traffic and residences or schools.
A major concern in service industries is the widespread continuous work at
computer keyboards or grocery store check-out counters, which in some coun-
tries has lead to "epidemics" of a number of painful hand and arm conditions
called occupational overuse syndrome (OOS), cumulative trauma disorders (CTD) or
repetitive strain injury (RSI). Stress from high demand for fast service work plays
a role in the onset of these conditions. Ergonomically well-designed work sta-
tions and limitations of continuous work through regular breaks can prevent the
condition (Yassi, 1997, Yassi, 2000).
Another occupational hazard in these types of industries is psychological
stress from the demands of person-to-person contact and the economic de-
mands for more rapid decision making and action. Verbal and even physically
abusive incidents are of increasing concern in the service sector, especially the
health and social service sector (Yassi and McLean, 2001). This industry is also
generally very labor-intensive. The varying demands for services can create great
uncertainty in the employment prospects of every worker, again leading to stress.
Indeed there is growing concern that job insecurity and psychosocial work or-
ganization issues, often characterized by high demands and low control, have be-
come the major work-related health hazard in developed countries (Sullivan and
Frank, 2000).
MAJOR CHEMICAL CONTAMINANTS OF CONCERN IN THE

GENERAL_ENVIRONMENT AND THE WORKPlACE
Toxic MetaLs
The principal toxic metals of concern in industrial pollution are lead, mercury,
cadmium, and arsenic, although chromium, zinc, copper, and other metals may
be of concern in some areas. It should be pointed out that human exposure to
these metals is common both in the workplace and the general environment. In
addition, families of workers can be exposed through dust brought home on dirty
work clothes. Exposure to toxic metals from food is addressed further in Chap-
ter 7.
Lead Lead is one of the oldest environmental hazards known to society. There
are many sources of exposure to lead, with residents in urban areas tending to
have lead levels that are higher than those in rural areas. Lead enters the body
primarily through the inhalation of tiny particles that contain it or through in-
gestion of food or beverages that contain it. Absorption of tetraethyl lead gaso-
line additive through the skin does occur, but such exposures have rarely caused
lead poisoning. Petrol sniffing among youth in certain communities has caused
significant poisoning problems. Lead remains a serious environmental hazard as
well as a serious occupational health and safety problem.
Lead was used long before the tndustrial Revolution for making pipes, pig-

ments, and bullets because it is a soft metal, is easily worked, and melts at a rel-
atively low temperature. Industrial pollution by lead has been a particular prob-
lem in smelters. Primary lead smelters handle ore that contains high concentra-
tions of lead. Other types of primary smelters may be associated with a risk of
lead exposure, because lead is often present in the ores of other metals. The most
common type of point source for industrial pollution by lead, however, has been
secondary smelters, where old lead batteries are torn apart, melted down, and
resmelted. These secondary smelters are often located in populated areas and lead
contamination of soil around them can be extensive.
Industrial pollution from lead, however, is a more general problem because
of leaded gasoline and lead-containing paints for indoor application. Tetraethyl
lead additive was for many years a major contributor to environmental lead ex-
posure in communities. Leaded gasoline has been withdrawn from the market
in most countries and where it has, the lead levels in the blood of children have
decreased. Another major source of community exposure to lead has been house
paint containing lead. Children who eat flaking paint chips or who play on the
floor where there is lead-containing dust from disintegrating paint are at risk for
lead poisoning. Currently, lead-containing paints are usually restricted to heavy-
duty outdoor painting of steel bridges and other nonresidential structures. How-
ever, paint stays on buildings for a very long time and any painted building older
than 30 years may still have lead paint.
Another important source of lead exposure was (and, in many countries such
as Mexico, still is) lead-based glazes on pottery. Lead can enter the food or bev-
erage contained in the vessel, especially if the beverage is acidic. Commercial pro-
duction of pottery with lead glazes has stopped in most of the world, but the
problem is still seen occasionally when a leaded glaze is used by an amateur or
when a decorative piece not made for drinking is used as such. Small amounts
of lead may also enter the body from food cans or copper drinking-waler pipes
because solder was used to seal them.
Heavy exposure to lead can result in lead poisoning, which is characterized
by anemia, kidney damage, nerve damage and partial paralysis of certain mus-
cle groups, and brain damage. The symptoms of acute lead poisoning are colicky
pain in the abdomen, nausea, and weight loss. The effects of lead exposure that
cause the greatest concern are those on children. Low levels of lead exposure
may cause irreversible brain damage that takes the form of learning disabilities
and reduced intellectual capacity. (Chapter 3 illustrated the various dose—response
effects of lead in children.)
Mercury Mercury is also an ancient hazard, however, it is much less common as

an industrial pollutant than lead. It is unique among metals, being liquid at room
temperature and readily volatilizing into a gas. There are many organic compounds
of mercury and these are usually more toxic than the metal element itself. Expo-
sure usually occurs through inhalation of mercury vapor or ingestion of mercury-
containing food, but mercury can also be absorbed across a wound or damaged skin.
Historically, mercury was primarily an occupational hazard, associated with
goldsmithing, mirror-making, explosive detonators, and the many uses of mer-
curial compounds as antiseptic and antifungal agents. The use of mercurial com-

pounds as an antifungal treatment of seed intended for planting has caused sev-
eral outbreaks of mercury poisoning, the most famous being in Iraq in 1972 in
which hundreds of fatalities occurred among people who used treated seed to
make bread. Industrial pollution with mercury was mostly on a small scale un-
til the 1940s, except for some mercury contamination of bodies of water from
gold mining. However, industrial pollution on a large scale resulted when the
chloralkali process was introduced in paper plants and production expanded dur-
ing the post-World War II era; this has resulted in substantial mercury contam-
ination in many bodies of water, particularly in the sediment where the mercury
accumulates. However, the largest outbreak of mercury intoxication in history
was the result of pollution from a vinyl chloride factory that used a mercury cat-
alyst in its production process. This occurred in 1953 at Minamata Bay on the
island of Kyushu, Japan, resulting in many deaths and a much greater number
of individuals with permanent neurological impairment. Effluent from the fac-
tory caused methylmercury contamination of fish, which were eaten by villagers.
Today, in most developed countries, mercury is primarily an occupational haz-
ard in dental clinics (from the use of a mercury-containing amalgam for filling
cavities), instrument manufacturing and repair, and smelting. Some cases of mer-
cury intoxication have occurred in homes, for example, where a space heater
has been used with a broken mercury-containing switch that was designed to
shut the heater off if it tipped over.
In some areas of the wcrld, such as the Amazon, mercury pollution is on the
rise. When gold was first discovered approximately three decades ago in Brazil,
thousands of impoverished Brazilians began to extract gold from river sediment
by mixing in mercury, as the liquid metal binds with the gold. The resulting amal-
gam is heated, causing the mercury to evaporate, leaving the gold behind.
Through this process large amounts of mercury were released into the air as well
as into the water.
The effect of mercury on the body can take many forms, depending on the
chemical form of the mercury and the circumstances of exposure. Metallic mer-
cury can cause mouth sores, extreme pain and tenderness in the fingertips,
tremor, and an unusual, pathological shyness that results from damage to the
brain. In the environment, metallic mercury is slowly converted to organic com-
pounds of mercury. Methylmcrcury compounds may cause severe nervous sys-
tem damage, both to the brain and the peripheral nerves. This is associated with
movement disorders, deteriorating handwriting, slurred speech, and visual ab-
normalities. The tragic experience of Minamata demonstrated that methylmer -
cury also causes severe fetal poisoning. In the Amazon region, villagers who ate
large quantities of fish contaminated by mercury at levels much below interna-
tional standards were reported to have neurological and cytogenetic damage (see
Lebel et al., 1996; Box 11.5).
Cadmium Another metal that has been used in a number of industrial applica-
ticns is cadmium. It is used as an anti-corrosive coating on steel, and in recharge-
able electric batteries. Cadmium compounds have also been used as pigments in
plastics, but in some countries restrictions on its use have been regulated to rc-
ducc the possibility of environmental contamination by cadmium.

The most famous cadmium poisoning outbreak due to industrial pollution is
(Kjellstrom,
the 'Etai-itai" disease epidemic in Japan, which started in the 1950s
1986a). Water pollution from a mine and lead/zinc refinery caused serious cad-
mium contamination to downstream irrigated farm fields. The farmers and their
families became exposed to high levels of cadmium in rice grown in contami-
nated water, and hundreds of cases of kidney damage occurred. The most severe
cases also developed severe osteoporosis and osteomalacia. A similar combina-
tion of kidney and bone disease has occurred in workers exposed to cadmium
(WHO, 1992f).
Cadmium accumulates in the body, particularly the liver and kidneys, and
the health effects usually develop after many years of exposure. This metal also
accumulates in the enviroment and its use in industry and associated pollution
has caused indirect exposures many years later. For instance, the mining pollu-
tion in Japan took years to build up to a health-damaging level. Similarly, cad-
mium contamination from industries to sewage water built up in sewage sludge,
which eventually was spread on farm fields. The increased cadmium concentra-
tions in soil produced increased concentrations in grains and an increased level
of human exposure. Fertilizers with high natural cadmium content add to the
problem. Thus some countries are regulating the use of cadmium to reduce hu-
man exposure.
Arsenic Arsenic is a more common element in uncontaminated soil than lead,

mercury, or cadmium. It is also bioconcentrated naturally in shellfish. As a re-
sult, many people have small amounts of arsenic in their bodies. In a number of
areas of the world, natural contamination of groundwater with arsenic is a seri-
ous problem, e.g.. in Bangladesh, India. Chile, and Argentina. In the past, ar-
senic compounds have been extensively used as antibiotics (particularly against
syphilis), as preservatives in tanning and taxidermy, as green dyes for paper, and
as antiparasile treatment in sheep dip. In each of these applications arsenic was
a serious occupational and consumer hazard. More recently, arsenic compounds
have been used in the doping of semiconductors and in other microelectronic
applications and present potentially serious occupational hazards to workers.
There have been deaths due to the accidental inhalation of arsine (AsH) a very
toxic gas, in this industry.
Arsenic is a carcinogen to human beings, causing skin cancer and lung can-
cer. Efforts to duplicate the carcinogenicity of arsenic in animals have not been
successful; it is the only known example of a uniquely human carcinogen. In ad-
dition, arsenic causes several types of skin rash. Because arsenic has a well-
deserved reputation as a potent poison, it is more widely recognized as a hazard
than other metals.
SoLvents
Solvents are liquids at room temperature that can dissolve other substances with-
out necessarily reacting with them chemically. While water is by far the most
common solvent, there are numerous other compounds that are used in indus-
try as cleaners, degreasing agents, extraction solvents, viscosity modifiers, con-
stituents of glues and paints, and paint or coating removers. These mostly or-

ganic chemicals are also widely used for niany nonsolvent applications as fuels,
pesticides, or chemical production lecdstocks. The most familiar organic solvents
are also important constituents of water and air pollution, frequently as the re-
sult of trace contamination from other sources or secondary chemical reactions.
Nonsubstituted hydrocarbons, ketones, and aldehydes occur in air pollution. Hy -
drocarbons, halogenated and nonsubstituted, are important in groundwater con-
tamination and water pollution.
Solvents can be categorized according to physkal properties or chemical struc -
ture. The basic physical properties of solvents can be described according to their
capacity to dissolve substances that carry a polar charge (typically, these com-
pounds are easily dissolved by water) or to dissolve nonpolar substances (such
as oils) (see Chapter 2). These characteristics of solvents are important determi-
nants of their human toxicity in the workplace, but they are not as important in
environmental exposures where the concentrations are much lower.
The various classes of solvents share a number of common characteristics
when it comes to human toxicity. Most solvents evaporate easily and are there-
fore easily inhaled in the workplace. Nonpolar solvents, those that dissolve oils
and fat, penetrate the skin very easily because much of the skin itself is fat; this
often leads to problems with skin rashes. Many solvents have essentially identi-
cal toxic effects on the central nervous system. They act as anesthetics and in-
toxicauts at high concentrations (ethyl ether and chloroform were the first anes-
thetics used in surgery) that may cause a complete loss of consciousness if the
fumes accumulate in confined spaces, but often lead to a clinical condition some-
times called painters syndrome because it often affects painters. In this syndrome,
the worker feels lightheaded then euphoric, loses coordination and acts intoxi-
cated, and finally becomes sleepy or very fatigued (acute central neurotoxicity).
In addition to the hazard of toxicity, workers may be more prone to injuries
and errors of judgment when under the influence of solvents. After exposure
stops, the worker will begin to feel depressed and often gets a severe headache
or feels ill. After many repeated exposures, the worker will become moody and
show a change in personality, becoming more irritable, and experiencing a loss
of short-term memory and eventually permanent brain damage. These symp-
toms are similar to those from intoxication with alcohol, except that the brain
damage typically occurs sooner than with alcohol. Certain compounds exert their
toxic effect on peripheral nerves, causing a loss of sensation or a burning sensa-
tion in the feet and hands. This condition is called peripheral neuropathy and it
can also occur as a result of alcohol abuse. Likewise, many solvents are highly
toxic to the liver and can bring about all the features of liver damage that can
be caused by ethyl alcohol, including cirrhosis. Cancer is a known risk for a few
of these solvents and is a theoretical risk for others. There is a large and con-
flicting literature on the possible cancer risks of particular solvents; for solvents
it is not clear whether they represent a significant hazard or not. A number of
solvents, particularly the glycols, are also highly toxic to the kidneys. (see Envi-
ronmental Health Criteria documents published by the WHO through its Interna-
tional Programme on Chemical Safety—see the website www.who.int/pcslfor on-
line publications.) These injuries may occur among workers who use these
solvents on the job without adequate protection; these effects are particularly

Seen in workers on spray-pamting operations. All of these effects can be pre-
vented by limiting exposure in the workplace to existing occupational exposure
standards. Nonetheless, cases of toxicity related to excessive exposure are very
common worldwide.
Benzene is the compound that most often appears in air and water quality-
monitoring data at concentrations sufficient to cause concern, in the air, the ma-
jor source of benzene is gasoline for cars. The exhaust fumes contain benzene,
which is spread to water supplies via runoff from streets during rain storms. The
potency of henzene as a carcinogen is known to he greater than that of most
other compounds commonly encountered in the environment. Also benzene
tends to he present at relatively higher concentrations in air and waler pollution
than those of many of these other compounds. This potency and the fact that it
is often present at significant concentrations mean greater importance is attrib-
uted to benzene than to most other chemicals when calculating the risks to hu-
man health.
Bulk Raw Materials

Any type of hulk materials that can induce adverse health effects after human
exposure needs careful handling to prevent accidental releases of large amounts
to the environment, fires, and long-term low-level emissions.. Examples of bulk
materials that can cause major hazards are chlorine gas, flammable liquids and
gases (oil, petrol, solvents, raw materials for plastics production, such as vinyl
chloride or acrylonitrile), and cyanides used in metals extraction and finishing.
Chlorine gas is stored in large volumes at many paper pulp plants and chem-
ical factories producing chlorinated organic compounds. The gas is heavier than
air and will therefore stay close to the ground after a release. It is highly irritat-
ing and damaging to the lungs and can kill people if sufficient amounts are in-
haled. Victims must be taken immediately out of exposure and given treatment
to restore lung function. Regulations exist in most countries concerning the safety
precautions required at a hulk chlorine storage site. These include warning de-
vices for any leaks, availability of breathing equipment, escape routes for work-
ers and people in the neighborhood, warning announcements to the commu-
nity, and emergency treatment facilities.
Flammable gases and liquids present a fire risk as well as a risk for exposure
to the toxic fumes created by any fire. The content of such fumes will depend
on the chemical composition of the bulk materials, and often the fumes are more
toxic than the hulk materials themselves. Because of the major economic dam-
age caused by industrial fires, precautionary measures are generally made a part
of routine management of the industry. Still, major industrial fires happen reg-
ularly in both developed and developing countries and the health impacts can
be important.
Cyanides are powerful solvents for certain metal compounds and are com-
monly used in gold extraction and metal plating and etching. The most toxic
compound, the deadly hydrogen cyanide gas, is formed when cyanides come into
contact with acids. The main health risks occur among workers in the industries
using cyanides, but leakage to waterways is another problem. Direct contact with
these chemicals affects the skin and lungs. In the waterways, cyanides will kill

fish, causing important economic hardship to people in the area. Large emer-
gencies have occurred when tailings dams at gold mines have leaked, as hap-
pened recently in Guyana and Romania. A much more common event is worker
exposure in small-scale electroplating industries, which use cyanide in corrosion
protection parts for car and metal products industries. In many countries this in-
dustry first develops as a small cottage industry, often in residential areas.
Chemical Poisoning in the Community
Exposure in the home is perhaps the leading means by which children come into
contact with toxic substances. Consumer education to promote awareness of the
potential toxicity of common products is urgently needed. Pesticides in aerosol
cans, bleaches, household cleaners, and cleaning fluids are potentially dangerous
to children and must be treated as such. Another need is for facilities to collect
and properly dispose of small quantities of hazardous waste. Individuals who find
themselves in possession of a bottle or can of solvents, pesticides, or some un-
known powder or fluid often do not understand the risk. Some decentralized
system for collecting such hazardous waste from consumers is needed before it
is poured on the ground, flushed down the toilet, or burned and released into
the air. Such a system has been introduced in many urban areas, involving home
or convenient pickup of small quantities of discarded toxic substances.
THE SOCIAL CONTEXT OF OCCUPATIONAL HEALTH

AND SAFETY
The field of occupational health and safety relates to the analysis and control of
hazards in particular workplaces. Occupational health primarily deals with haz-
ards of a chemical, physical, or biological nature; occupational safety primarily
addresses hazards of a mechanical nature. With increasing recognition that er-
gonomic factors can cause not only acute trauma but also repetitive strain in-
juries (e.g. occupational overuse syndrome, carpal tunnel syndrome, tendonitis,
and epicondylitis), occupational health professionals must consider biomechani-
cal factors within their realm of expertise as well. Psychosocial hazards of work
(e.g., stress, burnout, harassment) are also issues that occupaticnal health pro-
fessionals must address. (The WHO and the ILO have developed many impor-
tant documents in this area; the ILO's Encyclopedia of Occupational Health and Safety
[ILO, 1998] is an excellent source of information on the issues in this field.)
Although there is a great deal of variation worldwide in the nature and sever-
ity of occupational health and safety problems and the resources available to con-
trol them, there are many more issues in common. At the beginning of devel-
opment, whether historically among developed nations or currently among
developing nations, occupational health and safety tend to be a low priority be-
cause of a perceived need to develop at all costs. This is unfortunate, because at
this stage of development, a relatively small investment in worker protection may
yield great benefits in improved worker health.
As societies become increasingly developed, the field of occupational health and
safety tends to become an increasing priority. Often, a series of well-publicized ac-
cidents forces citizens to address this issue. Sometimes, trade unions force em-

ployers (and the government) to provide greater occupational safety. Occasion-
ally, a particularly enlightened employer sets the tone and is a model for the rest
of society. Historically, governments have taken the lead in controlling occupa-
tional hazards by setting permissible exposure levels and requiring periodic in-
spections for safe work practices.
Ideally, improving occupational health and safety is one area in which both
employers and workers would perceive a common interest. After all, occupational
injuries and illnesses are completely preventable and the costs that they impose on
the employer, the worker, and society in general are considerable. Employers lose
production time and skilled labor that must be replaced. They may, depending on
the health care system in the country, have to pay directly (or indirectly, through
taxes) for medical treatment. In countries where there are workers' compensations
systems, their insurance premiums will go up. Workers may lose their wages, their
chances for a better job, and, if permanently disabled, even their livelihood, not
to mention the pain and inconvenience in daily life that an injury causes the worker
and the anxiety this creates in the worker's family. Because occupational injuries
are common, the cost to society as a whole is enormous. However, the financial
incentive to employers to reduce occupational injuries and illnesses may be very
low if their direct costs are not clear or are borne by others.
Relationships between employers and workers often affect whether and how
occupational health and safety are addressed. Employers may be reluctant to
make the investment to control hazards in the workplace, especially if they feel
that their competitors do not. Governments may refrain from enforcing occupa-
tional health and safety standards because they are afraid that this may affect
competitiveness in world markets. Workers may not cooperate with health and
safety measures because they are poorly aware of hazards. Alternatively, they
may feel compelled to accept high risk in order to keep their jobs.
Despite methodological difficulties, studies have shown that implementing oc-
cupational health and safety activities can save industry money, and imple-
menting ergonomic interventions, with full worker participation, is particularly
worthwhile in reducing the social and monetary costs of work-related injuries
(Nosman and Wells, 2000). As wages rise, the cost to society of missed work and
loss of production increases as well. Efforts to reduce the impact of occupational
illness and injury will continue to take on growing importance.
There are other issues in occupational health and safety that are common
worldwidc. Small enterprises, all other things being equal, tend to have more
dangerous working conditions than very large companies. The reason is that
larger operations usually have the resources to solve their problems and can af-
ford the protection more easily than marginal operations. Also, many very haz-
ardous jobs arc done primarily by small companies working under contract to
larger ones. Some government agencies have therefore provided smaller enter-
prises direct assistance in the form of consultation services to help them solve
their safety problems as inexpensively as possible.
The internal Responsibility System

Many government regulatory bodies for occupational health and safety have
adopted the policy of internal responsibility for larger enterprises. This policy

holds these companies responsible for controlling hazards and ensuring compli-
ance with occupational exposure standards. The government agency reviews their
performance, audits their procedures, and occasionally inspects the premises, but
does so less often than for smaller enterprises. A key feature of this system is the
joint health and safety committee, a committee that consists of representatives from
both management and workers who meet regularly to discuss occupational health
and safety problems. This system works well when the worker committee mem-
bers are elected, members are adequately trained, and the committee is given the
authority to conduct inspections and play an active role in carrying out changes
in the workplace. Large companies also often maintain their own occupational
physicians, occupational health nurses, industrial hygienists, and other special-
ized occupational health and safety professionals. These professionals can help
ensure that the joint committee is given the information it needs and is kept
abreast of scientific innovations. While there is evidence that joint health and
safety committees can play an important rcle in improving workplace health and
safety, equally important are the regulatory environment and the structure of
economic incentives (O'Grady, 2000) and workplace organizational factors
(Shannon, 2000).
Workers' Compensation
Beyond a certain level of development, societies tend to introduce an insurance
scheme for their workers to minimize the disruption that occupational injuries
can cause and to control the costs. In particular, the cost of lawsuits associated
with injuries and illnesses may rapidly grow out of control. The response to this
situation may take the form of social security programs that operate as a com-
prehensive health care system for workers and their families. Some countries
have used this to phase in more universal coverage for health services for their
population. It may also take the form of workers' compensation, a no-fault insur-
ance system funded by employers that compensates workers for health care and
lost earnings from work-related injuries or illnesses. Some jurisdictions also pro-
vide an impairment award, based on measurable loss of function, regardless of
whether the worker can continue working.
Workers have often had to give up their right to sue their employers in ex-
change for a comprehensive workers' compensation system, which is adminis-
tered by an impartial board responsible to government, e.g., as in Canada. The
Workers' Compensation Board (WCB), having obtained information from the
employer, the worker, and the worker's attending physician, decides if the
worker's health problem is work related and the extent to which it disables the
worker. The system tends to work reasonably well for injuries but less well for
diseases, many of which are mullifactorial in origin.
Some workers are particularly disadvantaged as they have to deal with racism
and sexism at work in addition to the health hazards of work. Particular prob-
lems facing women in the workplace arc discussed in the next section.
Women in the Workplace

The role of women in the workforce is more complicated than that of men, in
part because of social roles that women have been expected to assume, such as

that of wife or mother; in part because of reproductive roles, such as childbear-
ing and child nurturing; and in part because women have been directed into cer-
tain occupations and excluded from others. Traditional societies tend to have very
different roles for men and women in society and the division of work may be
determined by following cultural norms; in some tribes and countries, for ex-
ample, women farm and rear children while men hunt, weave, and manufac-
ture goods. Through the process of industrialization and urbanization these tra-
ditional roles tend to break down and women are often recruited into low
wage—paying jobs in manufacturing and service industries very early in a coun-
try's economic development.
In North America and Europe, economic factors tended to push women out
of the paying job market after the Industrial Revolution. Wages rose to the point
that only one wage earner was needed to support most families. For social rea-
sons, this position was considered to be the duty of the husband and father; the
woman of the household was expected to stay home. Briefly during World War
II, women entered the workforcc in large numbers to replace men in military
service. Following the war, however, the pattern of women staying at home re-
turned. The rise of women's rights in the 1970s in North America and Europe
occurred at a time when real wage rates were beginning to fall. Barriers to women
returning to the workforce lessened as women entered many occupations that
had previously been held nearly exclusively by men. With declining real wages,
families also increasingly required two wage earners to maintain their standard
of living. In addition, the number of single-parent families increased, the parent
in most cases being the mother, so she was responsible for earning the family's
income. The result was that what began as a movement toward social equality
of opporttmnity became a financial necessity for many families. Currently, changes
in productivity and declining real wages for workers in less skilled occupations
is creating a crisis of employment and underemployment for many families that
had been economically secure a few years ago. Because women generally earn
less than men and are disproportionately concentrated in occupations that are
made redundant by technology or subject to cutbacks, women risk being forced
out of the workforce again, but this time into poverty.
In developing countries, the situation is somewhat different. Women are of-
ten the primary family wage earners, especially when they work in industries
that produce goods for export, such as light manufacturing. Social barriers to
women earning wages break down rapidly with urbanization and the greater
availability of such jobs in many urban areas. The continued role of women in
rearing children, however, places a double burden on women who are also wage
earners in developing societies, and the risks of occupational injuries may jeop-
ardize their ability to provide primary care to their children.
Women show some differences in physical capacity compared to men. These
differences place women at a disadvantage for the relatively well-paying heavy
industrial jobs in manufacturing. On average, for example, women have less up-
per body strength than men and perform less well on tests of strength than men.
However, individual women may outperform most men on any physical tests,
and may have better endurance. In any case, such physical characteristics are only
meaningful in relation to a particular job specification and particular candidates;

they are irrelevant if the job is designed such that physical strength is not a fac-
tor. Women's productivity is equal to that of men or higher among employees
in most jobs where the comparison can be made. Women are at comparatively
less disadvantage in the rapidly growing service sector or light manufacturing,
although, as discussed by Messing (1997) much more attention is needed to oc-
cupational health issues facing women.
Women workers face specific problems that arise from their reproductive and
social roles and are often a disadvantage for promotion and career development.
Pregnancy leave and time for child rearing is a particular problem for female
workers, albeit many men lace problems too if they want time off to co-parent.
Many countries have legislated requirements for employers to provide pregnancy
leave (or even parental leave), usually unpaid but with a guarantee of return to
employment, on the grounds that the time spent nurturing young children is an
investment in society and the future. Child care is often a problem for women
who work out of the home. Women may have to take paid or unpaid leave to
take care of members of the family; as women are usually the caregivers in the
family, they may need to take care of sick or disabled children, spouses, or par-
ents. The social division of roles between men and women often leaves women
with the responsibility for the household and for food shopping, which translates
into less time for relaxation after the job.
Because women usually earn less than men in the same job, their loss of earn-
ings due to work-related injury or illness may not be protected to the same de-
gree by social security insurance, workers' compensation, unemployment insur-
ance, or private disability insurance. When they lose their job, these benefits may
pay less than for men because they are indexed to previous income. Where such
social safety nets are lacking, they may he faced with much greater difficulty
earning a living if they lose their jobs. Where no work is available and the hav-
ing situation is desperate, it is typical for men to resort to crime and for younger
women to resort to prostitution, which carries a high risk of disease, violence,
and exploitation. Inheritance and divorce laws frequently place women at a dis-
advantage, making single women even more dependent on their jobs.
Occupational hazards experienced by women may place others in the family
at risk. Reproductive hazards may affect a pregnant woman's fetus. Some toxic
exposures, such as those to lead and asbestos, may be carried home on either
parent's clothing and affect children at home. An occupational injury or illness
that can result in serious economic loss for a Iwo—wage earner lamily may thrmv
a single -pa rent household in to poverty overnight.
Sensitive employers seek to understand the needs of women employees, such
as the provision of child care, sensible absence policies that permit women to
take time off for caregiving, and working conditions that are free of hazards that
might affect the woman, the fetus in pregnancy, or children at home.
DIMENSIONS AND TYPES OF OCCUPATIONAL

HEALTH PROBLEMS
The Global Estimates for Health Situation Assessments and Pro fections has suggested
that there were 32.7 million occupational injuries and 146,000 occupational

deaths in 1990. Among exposed populations worldwide it is estimated that the
incidence of silicosis is 3.5%43.8%; byssinosis, 5%-30%; lead poisoning,
2.6%-37%; noise-induced hearing loss, 1.7%_70%; and occupational skin dis-
eases, 1.7%-86% (WHO, 1992e). Occupational health hazards can he classified
by the nature of the hazard, as was done in Chapter 2. The main groups are
chemical, physical, mechanical, biological, and psychosocial hazards. Examples
of the illness and injuries they can cause are given below.
Underdiagnosis and underreporting are known to be a large problem. Thus
official statistics are not reliable. In practice, the distribution of occupational dis-
eases in developed countries is thought to be approximated by the rule of halves,
which states that the distribution of occupational diseases in a large working pop-
ulation in a diversified economy tends to be divided as follows: skin disorders ac-
count for roughly half of all occupational illnesses; eye disorders, roughly half of
the remainder (or 1/4); lung disorders, half of that (or 118); and half of the resid-
ual are systemic toxicity problems. This general approximation holds true as a
rough guide for industrialized communities but may be distorted somewhat in
smaller communities where a single dominant industry presents an unusual haz-
ard, such as in ccal mining. It should be noted that this analysis does not include
musculoskeletal conditions, which arc quite widespread.
In developing countries, where underdiagnosis and underreporting may be par-
ticularly problematic, contact with communicable diseases, toxic substances, unsafe
machinery, extremes of heat and cold, and other hazards is made worse by a lack
of personal protective equipment (see Chapter 4). In addition, occupational health
services are lacking and standards have either not been adopted or are not enforced.
Common occupational diseases include respiratory diseases caused by particulates,
lead poisoning, pesticide poisoning, hearing loss, and skin diseases (Jeyaratnam,
1992; Baker and Landrigan, 1993). Flealth hazards in the workplace may also be
exacerbated by malnutrition or chronic disease. Nonalcoholic liver disease is wide-
spread in Africa and Asia and may make workers who suffer from it less able to
detoxify the toxic substances they encounter at work (Ong et al., 1993).
Occupa timal Chemical [-Jaza n/s
Chemical hazards are illustrated by the sections above on toxic metals, solvents,
and bulk raw materials. In general, occupational exposures to these and most
other hazards are much greater than exposures that occur generally in the en-
vironment. The workplace is an artificial, constructed environment that exists for
an economic purpose, and its primary function is to produce a product or ser-
vice. To do this, chemicals are often required as raw materials, for processes im-
portant to production, for maintenance and cleaning, and for transportation and
packaging. Even in offices various chemicals are used to produce documents,
maintain machines, and clean the workplace. It should not be surprising, there-
fore, that exposure to chemicals in the workplace is typically more intense and
oltcn more prolonged than exposure to most chemicals in the natural environ-
ment, at least for the people who work in that workplace. Much environmental
pollution reflects the release of some of these same chemicals into the environ-
ment, so that control of occupational health represents one approach to con-
trolling environmental pollution but primarily represents control of the some-

what higher exposures experienced by the people who work there. As discussed
in Chapter 4, the key to controlling exposure to chemical hazards is usually to
substitute less toxic chemicals for the same purpose, reduce the local concentra-
tions through ventilation or tighter containment, or use personal protection such
as respirators and gloves.
Chemical hazards may affect any organ system in the body (see Chapter 2).
However, some disorders are more common than others as a result of chemical
exposure in the workplace. Skin disorders are most common, particularly skin
rashes caused by irritation or allergies to the chemica]. Eye disorders, usually as-
sociated with irritation, are also common. Of the serious or life-threatening con-
ditions, the most common are respiratory disorders, including asthma, irritation-
induced bronchitis, and deep lung injury. The most common occupational lung
diseases are discussed in Box 10.3. See ILO (1998) or an occupational lung dis-
ease text (for example. Morgan and Seaton, 1995) for further details.
Ox 10. 3
Common Occupational Lung Diseases
PNEUMOCONIOSIS
The pneumoconioses are diseases characterized by the deposition of dust in the lungs
and the pulmonary response to its presence. The degree of fibrosis (scarring) that
results varies with the properties of the dust. Silica and the fibrous silicates, such as
asbestos or zeolite, cause intense fibrotic reactions. Carbon black or iron oxide pro-
vokes only small and localized reactions. Even relatively benign dusts may be asso-
ciated with more serious responses when combined with other exposures, such as
toxic gases or carcinogens that may adsorb on the surface of particles.
Ashestosis, often called white lung, is a common and serious pneumoconiosis re-
suIting from the inhalation of large quantities of asbestos fibers. The disease is a risk
for shipyard workers, plumbers and pipe titters, insulation workers, members of the
building trades, and many others working where asbestos had been used heavily
and without tight control. The natural history of the disease is progression of the
restrictive impairment, sometimes to total disability, and a very high risk of cancer.
The disease is not associated with smoking, but smoking clearly makes the symp-
toms worse and the management more difficult once the disease appears. Asbestos
exposure also causes lung cancer and the risk of this disease increases dramatically
in asbestos workers who smoke.
Silicosis is an ancient disease that continues today in numerous occupations. Sil-
ica exposure is a hazard of mining and quarrying, older techniques of sandblasting
and etching, foundry work, industrial and artisan ceramics, and innumerable occu-
pations in which finely pulverized silica flour is employed as a filler material. When
combined with tuberculosis, the resulting condition of silicotuberculosis can he a
devastating, swiftly progressive fibrotic process that resembles a malignancy. The
complication of silicosis by tuberculosis is common and may be devastating. The im-
paired lung cannot contain the tuberculosis infection and the result is an acceler-
ated fibrotic process that may require lifelong treatment with anti-tuberculosis mcd-
ication to control. Individuals with silicosis are predisposed to initial infection by the

nitinued)
tubercie bacillus once exposed or reactivated. They may also he vulnerable to other
bacterial infections.
Coal workers pneumoconiosis (CWP), or black lung, is probably the best-known dust
disease of the lung. This disease and other lung diseases associated with coal min-
ing are declining in frequency as a result of dust suppression in the mines.
TOXIC INHALATION
Toxic inhalation is a general term for the serious pulmonary toxicity of a variety of
gases presenting similar clinical patterns, including ozone, phosgene, chlorine, ni-
trogen dioxide, hydrogen fluoride, and many others. Exposure to these gases at the
levels required to produce this condition is usually the result of accidental release,
uncontrolled chemical reactions, or fires. Certain of these gases, particularly phos-
gene, chlorine, and nitrogen dioxide, are generated when plastic furnishings and in-
terior design fixtures burn, as in a hotel fire. In such combustion situations, cyanide
and carbon monoxide are also released and contribute to toxicity.
OCCUPATIONAL ASTHMA
Asthma is a complex of symptoms and signs resulting from reversible obstruction
of air flow. Usually asthma presents as wheezing and shortness of breath, occurring
repeatedly in isolated episodes, often immediately following exposure to a recog-
nizable allergen. In a few cases of asthma, cough may he the major symptom. In
occupational asthma, the agent may be difficult to identify and the pattern of air-
ways obstruction may he unusual or delayed. The easiest agents to identify are those
that are highly sensitizing and that trigger the familiar immediate hypersensitivity
reaction. Such conventional allergic sensitizers include animal secretions, ethylene
diamine, grain dusts, detergent enzymes, epoxy resin curing agents, and virtually
any organic or small-molecular-weight compounds, including metals such as plat-
inum salts.
A few produce reactions by mechanisms that are not typical of the common im-
mediate hypersensitivity reaction, such as grain dust, wood dust, formaldehyde,
pharmaceutical agents, and toluene diisocyanate (TDI), a particularly potent sensi-
tizing chemical used in the production of polyurethane plastics. Isocyanates in gen-
eral, and TDI in particular, are among the most common chemicals in industry, pre-
sent in most paints, coatings, and finishing preparations. Isocyanate-induced asthma
is particularly common in autobody shops because of the use of binders containing
isocyanates in fibrous glass repair work. In such cases, the responses may be mixed
with immune, irritant, and pharmacologic mechanisms playing some role. iso-
cyanates are both potent sensitizers and irritants, with either mechanism promot-
ing airway reactivity.
HYPERSENSITIVITY PNEUMONITIS
Hypersensitivity pneumonitis, known in the United Kingdom as extrinsic allergic a/ic-

olitis, occurs when a sensitized individual inhales respirable dust containing large
quantities of an antigen to which the patient mounts an immune reaction. The char-
acteristic symptoms of hypersensitivity pneumonitis are shortness of breath, fever,
chills, and cough, developing over several hours or days. Repeated exposure to the
same antigen leads to an inflammatory reaction in the alveoli, a scarring reaction,
and ultimately to permanent lung damage. Common antigens that produce this con-
dition include molds, detergent enzymes, pharmaceutical agents, minute arthropods
such as mites, and dust from vegetable matter such as grain or animal material such
as aerosolized droppings and urine from birds. A typical situation is "farmer's lung,"
in which such an exposure is likely to occur when farmers handle moldy hay. This

is an important serious lung disease to diagnose and treat. Identification and con-
trol of exposure to the offending antigen usually results in complete resolution of
a potentially grave illness.
INDUSTRIAL BRONCHITIS
Workers in dusty occupations, particularly steelworkers and grain handlers, may de-
velop a nonspecific chronic bronchitis (see Becklake, 1985; 1989). Cigarette smok-
ing may aggravate the bronchitis.
FUME FEVERS
There are two common types of fume fever, both involving mixed pulmonary and
systemic reactions to inhaled toxic agents. Metal fume fever results from exposure to
hot metal fumes, particularly zinc, cadmium, and copper. The illness is a self-
limited but highly unpleasant reaction, similar to influenza, developing an hour or
so after exposure and consisting of nausea, fever and chills, malaise, myalgias, and
leukocytosis. Metal fume fever lasts only 1 or 2 days and should not be confused
with toxic inhalation, which may result from exposure to high concentrations of
cadmium or nickel fumes or from high concentrations of volatilized mercury, or
with acute lead poisoning. Metal fume fever is most often seen when inexperienced
welders try to weld or cut metal that is galvanized or of mixed composition.
Polymer fume fever is a similar influenza-like reaction resulting from the pyroly-
sis products of Teflon and related polymers when particles settle on cigarettes and
burn, and the fumes are inhaled. Polymer fume fever can he prevented by banning
cigarette smoking in workplaces where products containing these polymers are fab-
ricated. Polymer fume fever should not he confused with "meat-wrappers asthma,"
a problem of bronchospasm and an irritant bronchitis resulting from the inhalation
of fumes generated when polyvinyl chloride film wrapping is cut using a hot wire.
This used to he a common problem in supermarkets but has since been solved by
adjusting the temperature of the hot wire.
Some chemicals affect the reproductive system in either men or women and
can cause sterility, miscarriages, or birth defects. Table 10.1 lists agents that have
been reported to adversely affect reproductive capacity. Table 10.2 summarizes
known or highly suspect carcinogens in the workplace.
Neurotoxicity is another serious problem associated with both heavy metals
and solvents, as described in the sections above, and with other chemicals. Like-
wise, liver and kidney toxicity are common responses to chemical exposure. Re-
cently, there has been much attention given to the effect of chemical CXOSUC
on the immune system. It seems likely that research in this field will yield many
insights into subtle health effects that are currently not known in detail.
Physical Hazards
Physical hazards are also very common at worksites. Noise is by far the most
widespread of the occupational hazards, and the high incidence of noise-induced
hearing loss worldwide demonstrates that it remains one of the most poorly con-
trolled. (Chapter 4 provided an example of an occupational noise control pro-

TABLE 10.1
SELECTED AGENTS REPORTED TO AFFECT REPRODUCTIVE CAPACITY
ANTINEOPLASTIC AGENTS
Alkalaung agents, alkaloids, antiinctabolitcs, anti-tumor antibiotics
CENTRAL NERVOUS SYSTEM DRUGS
Alcohol, anesthetic gases/vapors
METALS AND TRACE ELEMENTS
Aluminum, arsenic, beryllium, hora nes, boron, cadmium, cobalt, lead (inorganic and Organic),
manganese, mercury (inorganic and organic), molybdenum, nickel, selenium, silver, uranium, zinc
INSECTICIDES
Benzene hexachlorides (lindane), carbamales )carbaryl(, chlorohenzene derivatives (DDT,

methoxychlor), indane derivatives (aldrin, chlordane, dieldrin(, phosphate esters (dtchloro, hexa-
methylphosphoramide), miscellaneous (chlordecone)
HERBICIDES
Chlorinated phenoxvacetic acids (2, 4-dichlorophenoxyacelie acid. 2, 4, 5-Irichlorophenoxyacetic

acid) quaternary ammonium compounds (diquat, paraquat)
RODENTICIT) ES
Metabolic inhibitors )Iluoroacctate)
FUNGICIDES, FUMIGANTS, AND STERILANTS
Apholale, captan, carbon disulfide, dibroniochloropropane, ethylene dibromide, ethylene oxide,

thiocarhamates, triphenyltin
FOOD ADDITIVES AND CONTAMINANTS
Aflatoxins, cyclamate, diethylstilbestrol, dirnethylnitrosamine, gossypol, metanil yellow,

monosodium glutamate, nilrofuran derivatives
INDUSTRIAL CHEMICALS
Aniline, carbon monoxide, chlorinated hdrocarhons hexalluoroacetone, polybroinated biphenvls,

polychlorinated hiphenyls, tetrachloro-dihenzo-p-dioxin(, ethylene oxide, formaldehyde, hydrazine,
nionouiers (vinyl chloride, chloroprene), polycyclic aromatic hydrocarbons, solvents (benzene, car-
bon disullide, glycol ethers, epichloroliydrin, hexane, thiophene, toluene, xylene), toluene rioso-
cyanate
MISCELLANEOUS
Physical lactors (heat, light, hypoxia), radiation, certain infectious agents -
Soirce: McGuigan. 1902.
gram.) In son-ic countries, excessively hot or cold working environments are corn-
mon. There are also sources of ultraviolet irradiation outdoors and in some work-
places that have effects like those described in Chapter 11. Ionizing radiation, is
a familiar type of exposure because it is common in health care settings and is a
risk in the nuclear industry, as noted in Chapter 9. Although laser light (because
it is so concentrated) is a serious physical hazard in some technical settings, lasers
used in applications such as supermarket checkout counters are too low in en-
ergy to induce injuries.

TABlE 102
SELECTED KNOWN OR HIGHLY SUSPECT CARCINOGENS IN THE WORKPLACE
Substance Where Encountered
Acrylonitrile Plastic and textile industries
Arsenic Very widespread
Asbestos Very widespread, especially in construction, auto repair,
shipbuilding; present in many products
Auramine and magenta Dye manufacturing
Benzene Very widespread in industry as sol Vent and chemical
con St ii ii en I
Benzidine Clinical pathology laboratories; chemical dyestuffs, plastics,
rubber, wood products
13-naphthylamine Chemical, dyestufls, and rubber industries
Bis(chloroniethyl) ether (BCME) Chemical industry, nuclear reactor fuel processing
Carbon tetrachloride Very widespread
Chloroform Chemical and pharmaceutical, textile, and solvent industries
Chloromethyl methyl ether Chemical industry
(CMME)
Chioroprene Synthetic rrtbber industry
Chromate (hexavalent) Electroplating, metal products, photographs, textile industries
Coke oven emissions Steel mills, coke ovens
Cutting oils Machining, metal working trades
Ethylene dibronude Foodstuff (fumigation), gasoline, additive industries, pesticides
Ethyleneimine Chemical, paper, and textile industries
4.4-methylene-bis Plastics manufacturing: elastomer, epoxy resins,
(2-chloroaniline) polyurethane foam
Hydraztne Mechanical applications, pharmaceutical industry
Ionizing radtation Very widespread, especially medical and industrial X-ray
Leather dust Leather goods industry
Nickel Widespread, especially in metal products, chemicals, battery
i rid u strics
N-nitrosodimethylamine Chemical, rubber, solvent, and pesticide industries
Polychiorinated biphenyls (PCB5) Very widespread, particularly in utilities, electric power,
chemical and wood products industries
3,3-dichlorobenzidine Pigment ntanufacturing, polyurethane production
Trichlorethylene Previously very widespread use as solvent and degreasing
agent, now withdrawn from use
Ultraviolet light Ubiquitous
Uranium and radon Underground mining
Vinyl chloride Petrochemical, plastics, and rubber industries
Wood dtist Hard wood industries
For Snore information on carcinogens as classilied by various organizations, see www.esli.bn ].gov/cms/car
(inogens.
Mechanical Hazards
Mechanical hazards may be of two general types: unsafe working conditions and
ergonomic hazards. The science of ergonomics generally includes the control of
hazards that may result in acute injury as well as chronic disorders usually of
the musculoskeletal system, as noted in Chapter 2. Unsafe working conditions
are those that may allow a sudden release of energy (such as an overly pressur-
ized gas cylinder) that can cause injury or that place the worker at risk of injury.

BOX 10.4
Infectious Diseases in Sewage Workers
Sewage is a mixture of liquids and solids of domestic and industrial origin that varies
in composition from sewer to sewer and from hour to hour. Workers processing
sewage and maintaining sewage systems are exposed to a variety of biological haz-
ards. An increased risk of self-limited diarrheal diseases has been reported in sewage
treatment workers employed in various jurisdictions. Leptospirosis is a well-known
occupational disease of sewage workers. Giardiasis has also been reported as a risk.
Some but not all studies have revealed increased evidence of hepatitis A infection
in sewage workers. In communities where there has been epidemics of hepatitis A,
occupational transmission of this infection has been reported.
Contributed by A. Kraut, University of Manitoba. Canada.
such as a fall, laceration, or a sprain. The key to controlling unsafe working con-
ditions is to reduce the amount of energy that could be released and to build in
guards, harriers, and other devices that protect the worker.
Ergonomic hazards result from a mismatch between the worker's body and
the design of the workstation. The result is a disproportionate strain that is placed
on an intrinsically weak part of the body—e.g., a chair fails to support the hack
properly or a work station is designed in such a way that the worker must stretch
to perform a common task. The usual result is an injury that results from the cu-
mulative effect of the strain, not a single injury event. Repetitive strain injuries
among typists and keyboard operators, assembly line workers using vibrating
tools for prolonged periods, or supermarket checkout clerks who handle items
with repetitive motion at the wrist are examples of ergonomic hazards (see Yassi,
1997; 2000 for a review of this topic).
Biological Hazards
Biological hazards are most obviotis in health care and agriculture but may oc-
cur in many other industries. Infection with one or more viruses that cause he-
patitis is another major concern. Tuberculosis (TB) is a serious problem among
hospital workers. Infection with the human immunodeficiency virus (HIV) (the AtDS
virus), or with the hepatitis B virus can occur from needlestick injuries or blood
contact and, understandably, is widely feared. Leptospirosis, a bacterial infection
spread by contact with rat urine, occurs in some occupations and is a risk in the
sugar cane industry. Brucellosis is another disease of farmers and slaughterhouse
workers and is caused by contact with cows, pigs, and goats. Sewage workers
are at risk for some of these infectious diseases (although not TB or AIDS; see
Box 10.4).
Problems associated with allergies and reactions to organic products are com-
mon in agriculture. Enctunters with poisonous or otherwise hazardous species

can occur in clearing brush and working in remote areas, especially in the trop-
ics. These problems tend to be highly specific to particular areas and so it is dif-
ficult to generalize about them.
Psychological Hazards
As discussed in Chapter 2, it is now generally accepted that stress at work is as-
sociated with lack of control over the working environment and with high work-
place demands. Such stress-producing circumstances, however, are precisely what
has been created in the workplace as a result of economic restructuring. In this
vein, expectations of behavior in the workplace that show commitment and a
drive for increased productivity may be seen as positive to managers and stress-
ful by workers. The psychological stress from being unemployed can also be se-
vere. Generally, it is difficult to separate out stress at work from stress in daily
life.
INDUSTRIAT. FNVTRONMENTAT ACCTDF.NTS
Table 10.3 lists examples of the major environmental disease outbreaks that re-
sulted in a substantial number of reported deaths or severe illness. Numerous
other incidents have been reported with fewer reported cases of illness, often
because of effective management of the mishap. The accidents listed in the table
include only chemical poisoning outbreaks in the community around an in-
dustry or in the community consuming certain contaminated food products.
Some of these have been due to sudden accidental releases of chemicals, such
as the Bhopal case, and others have involved long-term low-level pollution that
finally reached danger levels, such as the Toyama case. These major poisoning
TABLE 103
SELECTED MAJOR "ENVIRONMENTAL DISEASE" OUTBREAKS DUE TO

NONRADIOACTIVE CHEMICALS
Location Environmental
and Year Hazard Type of Disease Number Affected
Toyama, Japan, Cadmium in rice Kidney and hone disease 200 with severe disease,
19505 )ltai-itai disease') many more with slight
effects
Minamata, Japan, Methylmercury Neurological disease 200 with severe disease,
1950s in fish ('Minamata disease') 2000 suspected with
disease
Fukuoka, Japan, Polychlorinated Skin disease, general Several thousands
1968 hiphenyls in weakness
food oil
Iraq, 1972 Methylnmrcury in Neurological disease 500 deaths, 6500
seed grains hospitalized
Madrid, Spain, Anilin or other Various symptoms 340 deaths, 20.000 cases
1981 toxin in food oil
Bhopal, tndia, Methylisocyanate Acute lung disease 2000 deaths, 200,000
1984 poisoned

outbreaks of an epidemic type are those that receive the most attention and
become known as classic environmental diseases. However, it should not be
forgotten that lOflg-tCflTl pollution situations, such as the high level of partic-
ulate pollution in many major cities of developing countries, leads to a much
greater public health impact than the dramatic outbreaks. If these dramatic out-
breaks serve as warnings of what can happen if proper prevention is not ap-
plied, their negative consequences can perhaps he balanced by unproved pre-
vention in the future.
As mentioned in previous sections, major accidents due to lires in industries
are not uncommon. Injuries can be dramatic, and both the burning materials
themselves and the smoke may contain very toxic compounds. The water and
fcam sprcad on fires by firefighters can, of course, contain the fire, but they can
also spread the pollution of chemicals burning or chemicals stored on the burn-
ing premises. Depending on the type of chemicals involved, the current advice
to firefighters is to let the fire burn out, and to use water and foatn only to cool
surrounding buildings so that they do not catch fire. Radioactive contamination
from fires in nuclear power stations or other nuclear installations a particularly
dangerous problem. The lire in the Chernobyl power station in 1986 is the most
dramatic accident of this type (WHO, 1995c).
Apart from fires, major natural disasters, including earthquakes, landslides,
floods, and storms, can lead to damage to industrial installations and accidental
release of environmental hazards. Prevention of serious injury involves careful
planning of the siting of installations, so that they are protected from these nat-
ural hazards to the extent possible. In addition, emergency plans and drills in-
volving workers and the community should be established.
APPROACHFS TO PREVENTiON
Applying a Pretntion Franit'work

The principles of managing risks and ccntrolling hazards were introduced in
Chapter 4. Prevention of injuries and diseases from occupational health hazards
is based on two basic concepts: (I) the work environment and the production
technology itself should he designed so that health risks are reduced to a mini-
mum, and (2) the worker should he educated and encouraged to behave safely
and use protective equipment. In the former case, the main responsibility for en-
suring a safe and healthy workplace lies with the employer; in the latter case, a
major part of this responsibility is shifted to the employee. In most situations
both concepts apply, but it has been shown in many countries that focusing on
improving the work environment and avoiding the use of dangerous processes
rather than merely telling workers to be careful is the most effective preventive
approach.
Human errors do occur in all of life's situations, but the impact of such er-
rors can he reduced by building health and safely into the work environment.
Countries that have developed policies for a healthy work environment in col-
laboration with employer and worker organizations have been particularly ef-
fectivc in reducing occupational injuries and diseases.

Creating a healthy work environment involves a series of decisions, includ-
ing the following:
Can the process be designed so that the raw materials are as sale as pos-
sible?
For instance, if the paints used in painting the products use less toxic solvents
(the least toxic is water), the workers will be at less risk of poisoning. The UNEP
has coined the term cleaner production for this type of choice.
Can the production machinery be contained so that noise, chemicals, and
dangerous machinery parts are kept away from the workers?
For instance, if paper production machines or printing presses are encapsu-
lated at all times when they are in operation, the workers at the machine can
he protected from loud noise, leakage of chemicals, and physical injuries. Mod-
ern video and computer equipment make it possible to monitor the functioning
of the different parts of the machinery without workers directly observing or
handling the parts when they are in operation.
Can levels of hazards in the work environment be reduced SO that adverse
health effects are prevented?
To give guidance on the maximum exposure levels that can be accepted,
whether for noise, radiation, chemicals, or biological hazards, most countries have
developed lists of occupational standards. These appear under different names, de-
pending on the country; e.g., maxim urn allowable concentrations (MAC5), threshold
limit values (TLVs), standards, and guidance values. In some countries these are
legally binding levels. In others they are aims that industry should strive for, but
exceeding the guidance limits does not involve penalties. The derivation of oc-
cupational exposure standards is discussed further in the next section.
What type of personal protective equipment is needed for individual pro-
tection of workers?
For emergency operations and certain maintenance operations, it is clear that
special protective equipment is needed. Preferably, the need for such equipment
in continuous daily work situations should be reduced, because almost all equip-
ment of this type causes difficulties for the wearer. Comfort and ease of use are
just as important as the equipment's protective efficiency. A variety of products
are available worldwide, and improvements and innovations in equipment de-
sign should be sought and encouraged.
What types of encouragement and training do workers need to ensure safe
operation of the process and appropriate use of protective equipment?
All people working in industry—employers and supervisors, as well as work-
ers—need to have a strong health and safety attitude and commitment. Encour-
agement for workers is best provided by industry leaders who invest in a safe
working environment and participate in a dialogue about how health can be pro-
tected within the industry. Collaborative decision making in health and safety
committees, combined with targeted training for all has been successful in many
countries. Training for employers and supervisors is equally important.
What type of monitoring, evaluation, and reporting will contribute best to
the encouragement of a strong health and safety attitude?
Measurement of the levels of the different hazards in the work environment,
monitoring of injuries and other health damage, epidemiological analysis, eval-

TABLE 10.4
PRINCIPLES OF TESTS OF WORKERS IN OCCUPATIONAL HEALTH SURVEILLANCE
The information obtained must be of demonstrable importance to the health or safety of the
worker being tested.
The test should not be a substitute for eliminating or controlling the hazard.
The test results should be applied for the purpose of improving the health and safety situation at
the svorksite and maintaining or improving the health of the individual tested.
The test should be specific for that substance or the family of substances being studied.
If the test is to anticipate an effect, it should detect signs at an early stage.
The workers' baseline status (i.e., before exposure in the workplace) should be known to permit
later comparison and interpretation.
The lest must be acceptable to the workers; a test that is painful (beyond drawing blood), very un-
comfortable, or inconvenient must be clearly )ustificd and agreed upon by the workers subjected
to it.
The advantages of using a particular method to identify cases should be greater than the advan-
tages of using alternative measures.
Each worker should be informed of his or her individual and group test results as well as the
meaning and health implications of the results.
uatioll in relation to standards, and regular reporting to all workers creates

confidence and ownership of the prevention process. Each report should in-
clude conclusions for further preventive actions and timetables for their imple-
mentation and should he based on joint discussions between employers and
employees.
The principles of controlling hazards were introduced in Chapter 4; Table 10.4
expands on the principles of surveillance programs as they apply to the work-
place. Controlling industrial hazards, whether to prevent occupational injuries
and illness or environmental exposures that could have a negative impact on the
community, requires an interdisciplinary approach with all members of the en-
vironmental health team working together.
Occupational Exposure Standards

Different countries set their occupational exposure standards in different ways.
Most industrialized countries use occupational exposure levels (OELs, also called per-
inissible exposure levels in the United States and maximum allowable concentrations in
Europe), which are either peak or average concentrations that must not be
exceeded in the workplace over a particular period of time. The usual times are
either 8 hr or 15 mm, depending on the rapidity with which health effects can
occur.
The 8-hr OELs are average concentrations over this time period. A system of
averaging called the time-weighted averaqe (TWA) simplifies calculation; an 8-hr
TWA is the average of each measured concentration weighted by the length of
time it lasted during the work shift. The 8-hr TWA is fine for a standard 8-hr
working shift but it may not provide sufficient protection for workers who work
overtime or on longer shifts, especially against chemicals such as organic solvents
that are retained in the body. Sometimes toxic effects can occur with short cx-

posures to high concentrations, regardless of the overall average. In such cases,
I 5-min short-term exposure levels (STEL5) or instantaneous ceiling levels are used
as absolute maximum concentrations that cannot be exceeded under any cir-
cumstances.
The appropriate levels of standards are widely discussed and debated around
the world. Although individual countries often adapt standards to fit local con-
ditions, there is a strong tendency for countries, as they develop, to adopt a con-
sistent international set of standards. The European Community harmonized the
conflicting standards of its member states to ensure uniformity and consistency,
both for worker protection and to prevent unfair economic advantages for coun-
tries that did not enforce safe workplaces.
The most influential single body in recommending and promoting these
levels has been the American Congress of Governmental Industrial Hygienists
(ACGIH), which, despite its name, is international in its membership, has no
relationship to Congress or the U.S. government, and includes many occupa-
tional health professionals who are not hygienists. The ACGIH, through its
committees, establishes threshold limit values (TLV5), which are recommended
occupational exposure levels set to protect all or most workers (excepting those
with particular susceptibility) and are based on the best available evidence in
the scientific medical and hygiene literature. The ACGIH also establishes bio-
logical exposure indices (BEI5), which are special tests that detect a chemical or
its metabolite in the blood, urine, or expired air of a worker and that can be
used together with, or instead of, workplace measurements. The TLVs are of-
ten adopted, without change, by governments around the world as the basis
for their OELs.
Despite its prestige and authority, the ACGIH has been heavily criticized for
setting TLVs on the basis of inadequate evidence and being influenced by eco-
nomic issues. In particular, it has been accused of allowing a conflict of interest
by having industry representatives on its TLV committees. Its BEts have also been
criticized as being efforts to make workers "guinea pigs," blaming them for the
exposure rather than controlling exposure in the workplace. The ACGIH can be
defended on the grounds that its recommendations take into consideration what
was practical at the time and that any effort to set standards without the partic-
ipation of industry would be doomed to failure. The BEIs are also highly sensi-
tive and protect workers' health because they measure all the exposure that the
worker has actually experienced, not just what may be in the particular area of
the workplace where a monitor is set up.
Lists comparing standards in different countries have been published by the
ILO and the UNEP/IRPTC (see website irptc.unep.chuirptc). The WHO has pre-
pared health-based maximum exposure limits for a selection of chemicals and
produces jointly with the ILO and the UNEP a series of Environmental Health Cri-
teria that provide guidance on the exposure levels that may affect health (see
website www.who.int/pcs/). Similarly, the WHO continues to work jointly with
the International Atomic Energy Association, the Industrial Radiation Protection
Association, and other international agencies to produce guidance on safe expo-
sure levels to various radiation hazards.

Studv uestions
Consider the ethical issues that may arise in occupational health, particu-
larly with respect to the competing interests of employers and workers. As an
official or consultant attempting to solve a problem related to an occupational
hazard, how would you deal with these ethical issues?
Consider the situation for women in the workplace in you country. Is it
likely that their health is affected differently from men's health by the conditions
discussed in this section? If so, how?
Consider the differences between industry-related (i.e., occupational and
environmental) health problems in developed countries compared to those in de-
veloping countries. How do these differences influence the programs that must
be developed to manage these problems? Consider the role of the various pro-
fessionals involved in assessing and managing industrial pollution.

11
TRANSBOUNDARY AND
GLOBAL HEALTH CONCERNS
LEARNING OBJECTIVES

• describe the relationship between global ecological change and health
• summarize the evidence and the debates regarding these global health
threats
• identify the obstacles to resolving these problems and be able to formulate
strategies that encourage people to think globally and act locally
CHAPTER CONTENTS
Health Consequences of War Deforestation and Desertification

Modern Conventional Warfare Forest Ecosystem Changes
Chemical Warfare Forest Ecosystems and Global
Biological Warfare Change
Nuclear Warfare Biodiversity
Guerrilla Warfare, Terrorism, and Biological Significance of
Deliberate Environmental De- Biodiversity
struction Economic Aspects of Biodiversity
Ozone Depletion and Ultraviolet Loss of Biodiversity
Radiation Acid Precipitation
Ultraviolet Radiation
Stratospheric Ozone Depletion Transboundary Movement of Hazardous
Human Health Effects of Ozone Waste
Depletion Disasters
Climate Change and the Greenhouse Emergency Actions
Effect Natural and Technological
The Greenhouse Effect Disasters
Global Warming Psychological Effects of Disasters
Effects of Global Warming on Survivors
Causes of the Problem Global Chemical Contamination
Solutions to the Problem
368
We live in a time of rapid change on a global scale. Many of these changes hold
the promise of positive developments in quality of life and international cooper-
ation. Improved communication, rapidly expanding trade, and new technologies
that conserve energy and resources are just a few of the changes that have a
worldwide impact on society and may make tomorrow's world better than to-
day's. However, not all global developments are likely to he positive. Global ccc'-
logical changes, including those related to stratospheric ozone depletion, the green-
house effect, deforestation and desertification, loss of biodiversity, interregional
transport of pollution, and large-scale resource depletion, are having a major im-
pact on communities worldwide. The implications of environmental trends for
weather, human habitation, and food supply suggest serious trouble ahead. To
these environmental hazards, which are largely due to industrial development
or economic pressures on agriculture, must be added the environmental conse-
quences of intentional destruction from war. Willful destruction for military or
political advantage has become one of the major issues in global ecological change.
In the past, most of these environmental hazards and the effects of environ-
mental pollution were treated as local issues and were generally handled on a
local level by public health authorities. In recent years, however, the scope of
environmental issues has broadened considerably and there is no clear dividing
line between problems that used to be considered public health problems and
those that involve large-scale ecological change. The degradation of the envi-
ronment has become a major global problem, outstripping its local public health
dimensions and becoming a serious threat, perhaps even to human survival. We
begin this chapter by examining the intentional destruction that occurs in war -
fare, both because of its own damaging effects and because it interleres with the
international and regional cooperation needed to solve the other problems.
The general outline of the global ecological crisis is clear: rapid technological
development in the developed world introduces new potential hazards in a so-
ciety in which environmental degradation is historically severe but coming un-
der relative control. Rapid population growth and industrial development, based
largely on obsolete technologies in the developing world, accelerates existing en-
vironmental degradation. This is aggravated by poverty, urbanization without ad-
equate infrastructure, rural development policies that do not strengthen local
economies, and a limited economic base that is too often dependent on com-
modity prices. The problem of environmental degradation has become global in
three distinct senses:
There is now imbalance on the level of entire global systems, such as climate.
The distribution of familiar environmental problems, such as air pollution,
has become much more widespread and regionalized until these problems are
encountered worldwide and not just in areas of development and urban growth.
The economic and political systems that operate to create and sustain these
problems (but that might also hold the key to some of the solutions) have be-
come global to the extent that the world is rapidly becoming one large market
economy, beyond the capacity of governments to regulate effectively. Much of
this change deals with drastic increases in consumption levels of resources and
consumer goods, and rising expectations for consumption among developing
societies.
TRANSBOUNDARY AND GLOBAL HEALTH CONCERNS 369

HEAlTH CCVSFQUENCES OF WAR
The most destructive human activity is warfare. As noted by Garfield and Neugut
(1997), the 1960s expression "war is not healthy for children and other living
things" is so understated that one hesitates to attempt to define how unhealthy
war is. Not only is war intentionally destructive between the sides engaged in
fighting, but when modern warfare is practiced, the environment is another cas-
ualty. The first and most tragic consequence of war is the direct casualties, the sol-
diers and civilians who die or are maimed in the fighting, and their loved ones
who must carry on. Table 11. 1, with all the limitations and inaccuracies in data
collection of this sort, indicate that mortality rates from war rose dramatically in
the twentieth century. This was largely attributable to large increases in mortal-
ity during World Wars I and II. Prior to World War II, more war-related deaths
occurred due to disease than to battlefield deaths.
The need to support a war effort and the care required by those who are
wounded but survive place a burden on the society supporting the fighting. Mod-
ern warfare also strikes directly at the economic and logistical ability of the soci-
ety to make war, often by targeting the environment directly. Garfield and Neugut
(1997) suggest that civilian deaths compose 90% of all deaths in twentieth-
century wars.
In War and Public Health (Levy and Sidel, 1997), the impact of war on public
health is documented and suggestions of what health professionals could do to
prevent war and minimize its consequences are offered. With respect to the Gulf
War, for example, studies have shown that the war and trade sanctions caused
a threefold increase in mortality among Iraqi children under 5 years of age (As-
cherio et al., 1992). The suggestion that by using high-precision weapons with
strategic targets the Allied forces were producing only limited damage to the civil-
ian population was shown to be false, confirming that the casualties of war still
extend far beyond those caused directly by warfare.
Modern Conventional Warfare
The primary purpose of modern warfare is to defeat or debilitate the enemy's so-
ciety and support systems to control a strategic resource and thereby impose or
avoid political domination. This is in contrast to warfare in earlier societies, when
battles tended to be fought by smaller armies with limited force and the fighting
TABLE 11.1
ESTIMATED AVERAGE ANNUAL MILITARY DEATHS IN WARS, WORLDWIDE,
BY CENTURY
Average Annual Military
Average Annual World Mid-Century Deaths per Million
Century Military Deaths Population in Millions Population
17th 9500 500 19.0
18th 15,000 800 18.8
19th 13,000 1200 10.8
20th 498,000 2500 183.2
Source: Levy and SkId, 1997

was confined to soldiers or warriors. Sometimes, such battles were really only
rituals, hurting only a small fraction of the population, and the losers were taken
as hostages for ransom. Although there are many examples in history of horrific
wars undertaken with crude weapons that led to great suffering, such as the Hun-
dred Year's War in Europe, for the most part, the damage that could be done
was limited.
In the eighteenth century the so-called art of war changed and by the time
of Napoleon, new tactics and artillery had greatly increased the damage that one
army could cause. Scorched-earth strategies of intentional widespread destruction
were used by Russia to stop Napoleon and by General Sherman against the rebels
in the American Civil War. By the time of World War I, the world had had ex-
tensive experience with a type of warfare that made all civilians targets. Such
warfare did not hesitate to destroy the environment for the sake of depriving the
other side of food and shelter, and it aimed at shredding the fabric of civil soci-
ety to demoralize and confuse the enemy. The emphasis in modern warfare be-
came disruption of the economy and civil society, not merely the defeat of troops
and the destruction of military targets.
Displacing civilians by warfare and making them refugees is often part of the
enemy's strategy to occupy the conquered territory (ethnic cleansing was the term
used for this in the former Yugoslavia). Large movements of dispossessed people
reflect profound human tragedy, create problems for public health and primary
health care services, and add to crowding and overpopulation in the camps and
communities that receive them (see Box 11 .1 for environmental health manage-
ment issues in refugee camps). Children of refugees may he denied education or
health services and may face growing up in an unstable, hostile, and unfamiliar
society. Scavenging for food and firewood may cause local ecological damage.
As tragic as scorched-earth strategies and refugee movements are, given the
opportunity, people rebuild and carry on with their lives and the land usually
recovers. However, following chemical, biological, or nuclear warfare, land could
he contaminated for generations to come. These acts of warfare at least have a
military purpose in seeking to defeat the enemy. Armies intent on winning a war
are not generally interested in their environmental impact. In addition to this
largely intentional devastation, the arbitrary destruction and confusion that oc-
curs incidental to war leads to ecological damage from air and water pollution,
road building through sensitive environments, and troop movements.
Chemical Warfare
Chemical warfare, introduced on a large scale in World War I, involves the con-
trolled release of toxic chemicals, usually nerve toxins or intensely irritating agents.
When used in the field, these poisons are indiscriminate in their actions and may
affect civilians or troops on either side, as well as wildlife and domestic animals.
These agents can cause considerable local damage and may wipe out entire vil-
lages. As a consequence, they are often considered to be weapons of terror and
civilian intimidation rather than effective military measures. The agents that have
actually been used in recent years do not seem to be very persistent in the envi-
ronment, perhaps because armed forces that use them kncw that they may have
to enter and occupy the same area later. The storage of chemicals used for chem-

BOX 11.1
Environmental Health Management of Refugee/Displaced
Persons Camps
People who are suddenly displaced by the events of war and forced to migrate usually
take their belongings with them. Such refugees are forced to depend on foster assis-
tance to meet their most basic needs, such as food, shelter, medical care, and water.
In assesstng what public health measures are appropriate, officials in refugee/displaced
person camps must consider the following: the types of make-shift shelters being used,
the physical environment, the demographic profile of the people in the camp, and the
extent and type of disease circulating in the population. The goal of the resulting pub-
lic health measures should be primarily to prevent the occurrence and spread of the
diseases favored by this situation. The process of identifying needs and setting priori-
ties requires an immediate assessment of the population's health and nutritional sta-
tus, as well as a rapid environmental health assessment of the available accommoda-
non. A monitoring and reporting system should be established to assess the effectiveness
of the measures, and to ensure the timely detection of newly developed risks. Envi-
ronmental health measures taken should include the following:
SELECTION OF SITE AND ACCOMMODATION
• The site should be selected according to the facilities needed to provide hygienic
and healthy conditions. Flood areas and natural foci of infection must be avoided,
• The accommodation site should afford an adequate protection against inclement
weather conditions.
• Overcrowding should be avoided.
WATER SUPPLY
• Ensure that water is adequate in quantity and quality (consider access to water
treatment and cooking facilities), and protect the source of water and water sup-
ply facilities from pollution.
REFUSE DISPOSAL
• Build hygienic field toilets according to the planned length of stay.

• Provide waste water drainage, solid waste collection and disposal, and incinera-
tion of medical wastes.
FOOD WHOLESOMENESS AND FOOD HYGIENE
• Distribute dried and preserved foods. Prepare food individually. Place storerooms
(if they exist) and community feeding facilities under health surveillance, and
provide hygienic food preparation courses.
INSECT AND RODENT CONTROL
• Controls should he based on prevention.
In addition, provisions must be made for child immunization, health education, pa-
dent treatment, drug supply, medical personnel, and a health service scheme, in-
cluding a system for referrals to inpatient facilities.
Prvi'ided by Krui toslat' 7apak, Croatian National Institute of Public Health.
372
ical warfare has sometimes created a hazard, particularly over many years when
the containers begin to disintegrate. Although chemical weapons have been out-
lawed for a very long time by an international agreement known as the Hague De-
claration, there have been many documented instances of their use and many more
suspected incidents in which absolute proof has been lacking or controversial.
Biological Warfare
Biological warfare, which is even more difficult to control, involves targeted re-
lease of pathogeris such as viruses and bacteria. In the few instances in which it
has been tried, there have been limited outbreaks of disease involving local res-
idents and wildlife. The effects of biological weapons are short term and unpre-
dictable, but certain agents, are transmissible and could cause widespread epi-
demics. Because the weapons perform poorly in the battlefield and are unreliable
against civilians, biological warfare has been used only rarely, although it has
been often alleged. In recent years, world concern over biological weapons has
focused chiefly on the testing and development of these weapons and the use of
biological agents in laboratories released into the environment during studies to
develop protective measures. These weapons have been outlawed by the Geneva
Protocol since 1925. This was strengthened by a further Convention in 1972, to
which 100 countries subscribe. In recent years there have been fears that ter-
rorist groups would use biological agents.
Nuclear Warfare
The ultimate extension of ecological warfare is, of course, nuclear war, where
the target is both the people and the region. The massive destructive power of
nuclear weapons led to an impasse that dominated the latter half of this century:
both sides held such massive military power that any attempt by either side to
use nuclear weapons assured their mutual destruction. This climate of fear is
thought to guarantee that neither side would use these weapons, a terrifying ba-
sis for peace but, to many, an effective one. Since the collapse of the Soviet Union,
there is little immediate prospect of total nuclear war, but the proliferation of
nuclear weapons to other countries carries a grave risk that they will be used in
regional conflicts. Should a nuclear exchange ever occur, the regional devasta-
tion it would bring would be inconceivable: sudden death, fire, massive de-
struction, and slow death by radiation sickness for those survivors at the pe-
riphery. However, this would be only part of the impact. Release of radiation,
potentially carried many miles by wind and water, disruption and contamination
of food supplies, shortages of medical services and supplies, and the susceptibil-
ity to infection of tnalnourished and irradiated survivors would result in massive
casualties well beyond the initial blast zone. It is also possible that a massive ex-
change would propel huge quantities of debris into the atmosphere, creating dust
clouds that would block sunlight and cause a prolonged cooling of the earth's
surface called nuclear winter (see Robock, 1991).
The testing and production of nuclear weapons continue to pose a threat of ac-
cidental release and local contamination. The sites of several nuclear weapons plants
are reported to be seriously contaminated and radionuclides have been detected
in groundwater downstream from at least one plant in the United States, although

the details are usually military secrets. Test sites in the South Pacific used by the
United States after World War II have shown high levels of residual radiation and
radionuclide contamination decades after the test, which is not surprising consid-
ering the long half-lives of some decay products of uranium and plutonium.
Release to the atmosphere and across long distances was a serious concern
for above-ground nuclear testing and venting from below-ground testing, and
low levels of radionuclides such as strontium-90 were well documented to have
migrated with prevailing winds from test sites in the 1950s and 1960s, before bi-
lateral test ban treaties were negotiated between the United States and the So-
viet Union. In the current complicated world situation, there is somewhat more
concern over accidental release from deteriorating stockpiles or handling acci-
dents involving nuclear weapons.
Guerrilla Warfare, Terrorism, and Deliberate Environmental Destruction

In the twentieth century, there have been a number of regional conflicts in-
volving guerrilla warfare, where one side avoids direct engagement with the en-
emy and instead attacks periodically and without warning, often by ambush, and
seeks to escape into the surrounding countryside before an effective retaliation
can be launched. Guerrilla warfare is usually undertaken by a weaker, poorly
armed indigenous force against an occupying or dominant power with conven-
tional military resources. This form of warfare rapidly escalates into environ-
mental destruction because the dominant force finds it difficult to engage the in-
surrectionary force directly and so responds by destroying the villages and
countryside where the insurrectionary force is concealed and supported. Indeed,
destruction of the environment is often a military strategy to inflict damage on
the other side in a guerrilla war. In particular, the dominant forces have sprayed
tropical forests with herbicide, burned off vegetation, and employed carpet bomb-
ing of large areas, leaving craters and many unexploded bombs, and both sides
have commonly planted land mines. The result has been devastated forest growth
and the creation of deadly hazards that last well beyond peace or a cease-fire. In
many areas of the world today, buried land mines are a serious hazard, partidu-
larly for people working in agriculture. It is thought that there are 100 million
land mines, planted in some 64 countries. About 26,000 people, mostly civilians,
are killed or injured by mines each year (see Stover et al., 1997).
Terrorism is an increasingly serious concern for the world community. The
public health impact of terrorism is relatively small, in the sense that terrorist at-
tacks create only a small number of casualties compared to the much greater
number of deaths and cases of disability caused by more traditional hazards. Ter-
rorism creates a climate of fear and depends on a collective state of anxiety to
achieve its ends. There are signs, however, that terrorism may become more of
a direct threat to health. The 1995 terrorist attack on the Tokyo subway, with
the nerve gas sarin, caused over a dozen deaths and over a thousand casualties,
making it one of the most devastating such incidents on record. The same group
had also attempted attacks with biological agents. The apparently increasing ca-
pacity of some terrorist groups using explosives, biological and chemical agents
and the potential access of terrorists to biological or nuclear weapons raise grave
concerns about the future. The fear raised by the threat of attack adds to stress

and interferes with civil society, sometimes provoking a political reaction that re-
stricts human rights.
In recent years, a new type of environmental destruction has emerged that has
no apparent military purpose. This is the practice of ecological vandalism, where a
combatant, usually on the losing side, creates widespread ecological destruction as
an act of revenge. The most familiar example of this was the oil field fires set by
Iraqi troops in Kuwait during their defeat in the Gulf War. Huge clouds of smoke
created a massive air pollution event that took many weeks to bring under control.
OZONE PFPIETION AND ULTRAVIOLET RADIATION

In the stratosphere, the upper, relatively dense layer of the atmosphere, OZOflC
molecules tend to accumulate through the action of ultraviolet (UV) radiation
on oxygen molecules. The energy quanta in UV radiation disrupt the oxygen
molecule, which forms ozone (0 3 ). Ozone has accumulated over time in the
stratosphere, where it tends to absorb UV radiation and act as a partial screen
that protects the surface of the earth from higher levels of exposure. Reduction
of the concentration of ozone in the stratosphere reduces the absorption of UV
radiation and allows more to get through. Ozone depletion therefore increases ex-
posure to UV radiation at the earth's surface. (Many excellent publications now
exist on this subject; see, for example, Mungall and McLaren, 1990; WHO, 1990b;
Chivian et al., 1993; McMichael, 1993; McMichael et al., 1996; UNEP, 2000).
Ultraviolet Radiation
Ultraviolet radiation carries much energy and causes tissue damage in human be-
ings and animals (see Chapter 2, Physical Hazards). There are three types of UV ra-
diation, all of which differ in wavelength (see Fig. 11.1). The longest wavelength,
UV-C, carries the most energy but is almost completely absorbed by the upper at-
mosphere so it does not reach the earth's surface; UV-C will not be discussed fur-
ther here. Ozone in the stratosphere in particular absorbs UV radiation completely
in the UV-C range (200-290 nm) and a large proportion in the UV-B range (290-320
nm). This serves as a shield, reducing exposure at the earth's surface below the ozone
layer. UV-A carries relatively low energy and is less harmful. UV-B carries somewhat
more energy and causes skin damage and tanning in lighter-skinned people.
Stratospheric Ozone Depletion

Stratospheric ozone depletion is not to be confused with tropospheric (lower atmos-
pheric) ozone accumulation. Although the same molecule is involved, both types
of ozone have different health effects. Ozone in the lower troposphere is an air
pollutant and throughout the troposphere it is a greenhouse gas, but in the
stratosphere it provides a vital protective shield against potentially harmful UV-
B irradiation. Stratospheric ozone is regenerated by splitting and recombination
of oxygen when it absorbs energy from UV radiation (a process called photolysis).
Stratospheric ozone is only minimally affected by migration of tropo-spheric
ozone upward into the stratosphere.
At ground level UV irradiation is easy to measure at a single point in time
but trends are difficult to interpret. Attenuation of UV radiation may occur from

UV-C UV-B--.---11 UV-A
-
10 0 - 10 6
DNA Solar
damage ('action radiation at
spectrum') ground level I
CD
105
CD
a) Cr
Cu 0•
Mouse
(skin 0
10 2 cancer (action)
104
6
pectrY a)
cc
CD
cc CD
C)
> 1 o- 103 •0
CD
Cl)
C 0
a) C
C 100-fold I)
a) difference C
1 o- in biological 10 2
C))
0 effect 0
0 between x, y CD
w ><
I I 0
Cl)
1 -5 LL —— —— — y 10 1 C
CD
II
10 -6 100
260 280 300 320 340 360

Wavelength (nanometres)
Figure 11.1 wavelength composition of solar ultraviolet radiation at the Earth's surface,
and relative biological effect. From McMichael, 1993, with permission.
dust in the atmosphere, so that at any one location there may be considerable
variability in measurements from moment to moment and from year to year.
Carbon dioxide accumulation and increased cloud cover tend to offset ozone de-
pletion, introducing another set of variables that are poorly understood. Ozone
depletion may not be the only significant factor to take into account in project-
ing future UV-B radiation at ground level. All of these factors complicate the pro-
jections that scientists make regarding future trends.
Despite these technical problems the overall pattern is clear. Ozone levels in
the stratosphere are decreasing at several locations, most particularly at the North
and South Poles, and UV irradiation at the earth's surface appears to he increas-
ing in the areas beneath the thinning ozone ("ozone holes") (National Academy
of Sciences, 1992). This interpretation fits with the facts as we now know them.
There are early suggestions of a consistent increase in ground-level UV-B irradi-
ation in readings in the Alps, although the areas of maximal increase are over
the Poles and particularly the southern oceans where regular reduction in strato-
spheric ozone seems to have been most marked. It is expected that the first cv-

idence of substantial increases in surface UV-B radiation will be seen in New
Zealand, Australia, and the southern part of South America.
The stratospheric ozone layer was observed to be thinning over Antarctica about
20 years ago. Repeated observations have confirmed the attenuation and charted
its progress. in 1956-76, the first 20 years of observations from space, the ozone
layer was stable; since then, it has declined in thickness over Antarctica from about
300 to between 125 and 200 Dobson units (units of concentration in a vertical at-
mospheric column under standard conditions). The cause is the release into the at-
mosphere, and gradual diffusion into the stratosphere, of chemicals that destroy
ozone by catalytic action, particularly the chlorofluorocarbons (CFC5).
The CFCs release chlorine by photolysis in the atmosphere; this free chlorine
scavenges ozone and destroys it. One CFC molecule may destroy as many as
10,000 OZOflC molecules. Release of CFCs into the atmosphere occurs through
industrial activity, leaks, or the decommissioning of old refrigeration and air con-
ditioning units, as well as by use of aerosol cans that use the compounds as pro-
pdllants. Substantial progress on curbing CFC generation and release on a na-
tional level has already been made with the Montreal Protocol, an international
treaty calling for reductions in CFC production and emissions. However, given
the long half-lives of the CFCs (75 years or more), the emissions already released
are expected to persist in their ozone-depleting activity at significant levels well
into the 22nd century (National Academy of Sciences, 1992).
Human Health Effects of Ozone Depletion

Intracellularly, UV absorption results in breakage of covalent bonds in critical
macromolecules and may eventually lead to carcinogenesis, accelerated aging,
and cataracts. Those at greatest risk for direct effects of UV exposure on skin are
people with fair skin who sunburn easily. The human health effects of increased
UV irradiation due to ozone depletion include higher risks of non-melanoma skin
cancer, particularly squalm)us cell carcinoma and actinic keratitis, a premalignant
condition; malignant melanoma, cataract, and retinal degeneration; and possibly im-
paired immunological responses (Jones, 1987; Rundel and Nachtwcy, 1983; WHO,
1994a). Relatively minor but cosmetically significant effects may include acceler-
ated aging of skin and perhaps increased frequency of ptervgia, small wedge-shaped
tissue webs on the whites of the eye. Of these conditions, the effects on immune
status and the propensity for inducing skin cancer are potentially the most seri-
ous (Moan et al., 1989; Morrison, 1989). Figure 11.2 shows an estimate of the
increase in skin cancer during 1979-1993 and the ozone depletion during that
period.
The use of protective clothing, sunscreens, and eyeglasses (both tinted and
clear) may reduce the risk of individual exposure to UV light, as may changing
fashions in sunbathing and outdoor recreation. Measures taken by people to pro-
tect themselves against higher levels of UV radiation are likely to be less effective
as commercial sunscreens may be effective against UV-induced sunburn if they
have a high enough sun protection factor for the exposure period, but their ef-
fectiveness against UV-induced cancer is unproven. Other measures include dark
or reflective clothing, parasols, truly protective sunglasses, and hats. Increased
shade will be more difficult to ensure in deforested rural areas or dry areas.

30
25
a)
=
0)
Ca
20
0
0
, 15
=
a)
0
a 10
[]
65N 55N 45N 35N 25N 15N 5N 5S 15S 25S 35S 45S 55S 65S
Latitude
Figure 11.2 Estimated relationship between increases in stratospheric ozone depletion and
skin cancer induction by latitude. Front McMichael et al., 1996, with permission.
CLIMATE CHANGE AND THE GREENHOUSE EFFECT
Global climate change will occur as a result of changes in the balance of heat
taken on and retained by the planet. An increase in heat may lead to global
warming and chaotic weather conditions, and a decrease in heat may lead to
cooling, longer winters, and an increase in water trapped in the polar ice caps.
Human activity, primarily reflecting changes in industry and agriculture, causes
an increase in the amount of heat retained by the planet. This leads to an aver-
age warming of the earth's surface but with a great deal of local variation, which
makes it difficult to predict changes for local areas. Changes in climate of the
magnitude that is predicted may lead to many health problems related to heat
stress, natural weather disasters, changes in the distribution of vectors causing
human and animal diseases, new infectious disease patterns, unreliable crop pro-
duction, local food shortages, and flooding. Many of the health problems are
likely to he indirect, resulting from the social and economic consequences of these
effects (Leaf, 1989; Mungall and McLaren, 1990; Chivian et al., 1993; McMichael
et al., 1996; UNEP, 2000). The Intergovernmental Panel on Climate Change (IPCC),
which represents the concensus of the international scientific community (WRI,
1998), estimates that current emission patterns are likely to increase the average
temperature 1°C to 3.5°C by 2100, and raise sea levels 15-19 centimeters (IPCC,
1996). The effects could be devastating.
The Greenhouse Effect

The term greenhouse effect is used to describe how the earth's atmosphere acts like
the panes of glass in a greenhouse where plants are grown (see Fig. 11.3). Car-
bon dioxide, water vapor, and other gases in the atmosphere act like the glass in
the greenhouse. The glass in the windowpane is transparent to infrared radia-

Q Sun
Solar radiation
Some solar radiation is

Mesosphere
reflected back to space by
the atmosphere, clouds
andbyE arth's surface Some infrared radiation is absorbed
and re-emitted by greenhouse gas
Stratosphere and clouds the effect is warming
-
the lower atmosphere and

Earth's surface
by
~~ S
Absorption
Troposphere water vapor,
clouds and aerosois
/
Most incoming radiation Long-wave infrared
is absorbed by Earth's Earth radiation is emitted
surface and warms it from Earth's surface
f1igure 11.3 Diagranimatic representation of the greenhouse effect. From McMichael et

al,, 1996, with permission.
lion in sunlight, so the radiation passes through and warms the plants and inte-
rior of the greenhouse. However, the glass also insulates the greenhouse, trap-
ping the heat that is created when the infrared radiation is absorbed Likewise,
infrared radiation from the sun passes through the earth's atmosphere, but the
carbon dioxide and some other gases in the atmosphere tend to insulate the earth,
trapping heat. The greenhouse effect normally contributes to stability of the
world's temperature and maintains the biosphere within a temperature range
conducive to life—the earth absorbs a certain amount of heat and loses the same
amount by radiation; the carbon dioxide and water vapor in the atmosphere keep
the average temperature higher than it otherwise would have been.
Until recently, the earth's heat budget was said to be in balance, i.e., its av-
erage temperature remained stable. However, in recent years there has been an
accumulation of gases in the atmosphere that upset this balance. Certain atmo-
spheric gases trap too much heat from infrared radiation, so global temperature
rises. The exaggerated greenhouse effect and resultant global warming may re-
sult in changes in regional climate and weather patterns. The accumulation of
greenhouse gases appears to have raised average global temperature by an esti-
mated /2 to 1 0 Celsius from 1930 to 1990. These changes in average tempera-
ture have occurred more rapidly in the last 10 years than in any earlier period.
A warming trend has been apparent since 1980, and 1998 was the warmest year
ever recorded up to that time. Rises of several degrees more are predicted in the
corning century. In fact, an overall global temperature rise of 3°-4C degrees in
the next 50 years is predicted by some experts. This increase may seem small,
but on a global scale this average masks marked extremes of temperature and
that has substantial implications (Mungall and McLaren, 1990; WHO, 1992a; Chi-

vian et al., 1993; McMichael, 1993; McMichael et al., 1996). These changes are
happening much faster than ever before, even considering the rapid changes at
periods of transition at the end of the Ice Ages (Mungall and McLaren, 1990).
Global Warming
Global warming is likely to produce exaggerations in existing trends in weather
and to make extreme weather conditions more frequent. There is no simple pre-
diction as to what effect atmospheric changes will have on climate, except that
there will not be a uniform, stable trend of rising temperature. No one weather
pattern will predominate or envelop the planet.
Regional predictions are much more difficult than global predictions about
average temperature and are greatly confounded by local factors of land contour,
prevailing weather patterns (which may be disrupted), and proximity to the
ocean. The rise in average temperature is likely to be less at the equator and in
high latitudes, and greatest in mid-range latitudes where winters may he colder
and the summers considerably warmer than at present (Hansen et al., 1989;
WHO, 1992a; McMichael et al, 1996). Figure 11.4 shows how estimated global
temperature has increased during the last 140 years.
Effects of Global Warming

Changes in climate of the magnitude that is anticipated are likely to lead to cer -
tain important outcomes: health problems related to heat stress, natural weather
xi
0.4
0
0.2
E
0
c
C
0.0
ci)
cci
0
E
ci)
cci
-Q -0.4
0
-0.6
-0.8 I I I
1860 1880 1900 1920 1940 1960 1980 2000
Year
Figure 11.4 Combined land and sea temperatures, 1861-1994. From McMichael et al.,

disasters, changes in vector distribution and, consequently, infectious disease pat-
terns, unreliable crop production, and flooding (McMichael et al., 1996). Many
of the health problems are likely to be indirect. Unlike previous periods of rapid
change in climate, humankind is now dependent on an intricate system of agri-
culture, trade, and communication that threatens to be disrupted. Social disrup-
tions leading to violent behavior may also be a factor in situations of food short-
age or prolonged heat stress. Violent behavior has been shown to increase in
frequency in hot weather, leading to the possibility of increased incidents of civil
disturbance (Last, 1992; Chivian et al., 1993).
Major cities of the world may have increased numbers of very hot days each
year, and the heat waves may last longer. The effect of this on mortality is likely
to be diffuse, affecting all causes of death and not just cardiovascular causes. An
estimate of the likely effect of an increase in summer temperatures of only 2°C
can be derived from a surveillance study of heat-related fatalities in the major
cities in the state of Missouri from 1979 to 1987. In July 1980, a prolonged heat
wave of this magnitude occurred; the temperature exceeded the normal daily
maximum of 31°C for 21 days and exceeded 38°C on several occasions. Ap-
proximately 1 in every 4000 residents developed heat stroke and 1 in every 1400
developed a heat-related illness that was either fatal or required hospitalization.
An excess of approximately 300 deaths from heat-related conditions was ob-
served, somewhat under half due to heat stroke (Jones ci al.. 1982; see Fig. 11.5).
Global warming may disrupt ocean currents and establish anomalous flows
of air, comparable to the trade winds and jet streams. As well as causing more
prolonged droughts, global warming may increase the frequency of severe pre-
cipitation, especially in the tropics. The result may be an increase in the frequency
and severity of violent weather disturbances such as hurricanes, tornadoes, ty-
phoons, floods, and blizzards. In 1988, North America experienced a major
350
El Average temperature
300 • Deaths 27 >
CD
250 26 co
Cl)
C
CZ
200 3
25 CD
Cs
a)
r 150 CD
0 24
a)
.o 100
E
23 cD
0,
50
22 C -)
I
1979 1980 1981 1982 1983 1984 1985 1986 1981 1988
Year
Figure 11.5 Annual fluctuations in average summer temperature and heat-related health
in Missouri, USA, 1979-88. From McMichael, 1993, with permission.

drought associated with the previous year's El Nido, which is a periodic mid-
ocean upswelling in the southeastern Pacific. The high-pressure area displaced
the jet stream (a current in the atmosphere) northward and diverted rain-carrying
weather systems away from their usual region of precipitation. Whether this
episode was influenced by a global warming trend is unclear. The conditions that
were set up, however, appear to be very similar to those that would occur with
increasing ocean temperatures (Schneider, 1987; Mungail and McLarcn, 1990).
Agriculture may also be significantly affected by global warming. A combi-
nation of effects of global warming could lead to food shortages. The negative ef-
fects on productivity of increased temperature and aridity on crop yields and
growing ranges are likely to counteract the increase in growing yields predicted
for many crops as a result of increased availability of carbon dioxide. An unpre-
dictable consequence of climate change is the impact it may have on the distri-
bution of major pests affecting crop yields, and the subsequent effect on food
spoilage.
Global warming may cause a rise of about a meter in sea level over the next
50-100 years. Exaggerated tides may threaten low-lying cities and coastal zones.
Many cities and populated regions are built in low-lying coastal areas for histor-
ical reasons usually related to shipping access. Examples include Shanghai, Lon-
don, Bangkok, New York City, Tokyo, Osaka, Vancouver, Rio de Janeiro, Bom-
bay, Saint Petersburg, Dar es Salaam, New Orleans, almost all of Bangladesh, and
most of The Netherlands. These population centers face significant flooding
threats due to global warming (Last, 1992; Chivian et al., 1993).
Through the impact of climate on temperature and geochemistry of the world's
oceans, the functional relationships within marine food webs may be altered.
Thus one finds increasing evidence of coastal eutrophication and altered phyto-
plankton biomass and species dominance. Paralytic, diarrheal, neurologic, and
amnesic shellfish poisoning as well as ciguatera, pufferfish, and scromboid fish poi-
soning, all related to algal biotoxins, appear to be spreading in a global epidemic
of coastal algal blooms (Anderson 1992; Smayda and Shimizu, 1993). These ef-
fects, along with the changing environments from many other stresses, have di-
rect consequences for human health and nutrition (Rapport 1995a, 1995b, 1997;
see Box 11.2).
The distribution of vegetation would also change drastically in a short period
of time, relative to the past rate of change on earth, if global warming occurs on
a massive scale. One likely consequence of this redistribution of vegetation ranges
is expansion in the geographical range of insect vectors of human disease, in-
cluding that of anophelene and colicine mosquitoes. The arthropod-borne virus dis-
eases may extend their range, including viral hemorrhagic fevers such as yellow
fever, dengue, and different types of viral encephalitis. Malaria may also extend
its range. In fact, evidence suggests that this has already been occurring (see
Box 11.3).
Box 11.4 illustrates how tick-borne diseases, such as typhus and Lyme dis-
ease, may change in distribution because of the change in range of the ticks'
mammalian host species. Schistosoiniasis, which is caused by a tropical and sub-
tropical waterborne parasite that depends on a snail host, is also likely to spread
as the range of its host expands, particularly with more damming for water con-

BOX_11.2
Emerging Diseases Related to Changes in Marine
Environment Source
Coastal marine environments are being altered as a result of excessive loading of

wastes and nutrients, as well as physical restructuring (e.g., reclamation of wetlands,
building of harbours), overharvesting of fish, and other stresses. These changes cou-
pled with local rises in sea temperatures have led to the emergence of new diseases
and the resurgence of old ones. A few examples are illustrative of changes over the
past decade:
EMERGENCE OF PFIESTERIA PISCIDA: THE "AMBUSH PREDATOR"
This species is responsible for major fish kills in Maryland, North Carolina and off
the Florida coast.
ASSOCIATION OF PERIODIC OUTBREAKS OF VIBRIOS WITH ALGAL BLOOMS
In Asia, there has long been an association between the seasonal appearance of
cholera and the yearly blooms of algae, zooplankton, and sea plants in coastal wa-
ters. Recently discovered is the nonculturable form of V cholerae in a wide range of
marine life (research by International Center for Diarrheal Diseases Research,
Bangladesh). In unfavorable conditions, V. cholerae assumes spore-like, quiescent
forms; with proper nutrients, pH, and temperature, the bacteria revert to a readily
transmissible and infectious state. V. cliolerae and V. vulnificus are present in coastal
waters of the United States. The latter is associated with a 67% case-fatality rate
among those with preexisting liver disease.
INCREASED PREVALENCE OF BACTERIAL AND VIRAL DISEASES
Both viral and bacterial diseases from the marine environment are on the increase.
Hepatitis A and bacterial diseases such as salmonella and campylobacter infections
continue to be major health problems throughout the world. A recent multistate
outbreak of viral gastroenteritis was related to the consumption of oysters from a
few U.S. states.
contributed by D. Rapport. See also Epstein and Rapport, 1996.
servation in and regions. The endemic zones of diseases currently limited to the
tropics are likely to extend into currently temperate zones. It is also possible that
such diseases will extend their ranges vertically to higher altitudes, especially in
the tropics (WHO, 1990b; Chivian et al., 1993; McMichael Ct al.. 1996; WRI,
1996).
Causes of the Problem

The reasons for this projected change in climate are complex, but all relate to
the release of increasing amounts of greenhouse gases, such as carbon dioxide

BOX 11.3
Climate Change and Malaria
Even a change in only several degrees in temperature, along the lines predicted by
the Inter-Governmental Panel On Climate Change (McMichael et al., 1996) can
have major effects on the vectors that transmit infectious diseases. In Rwanda, tem-
peratures increased greatly between 1961 and 1990, reaching a peak in 1987. In
the mid-I 980s, malaria became established in areas where it had previously been
rare or absent. Among people in high altitude zones, the incidence of malaria in-
creased more than 500%. Experts feel that the high temperatures and large amounts
of rainfall accounted for 80% of the difference in the monthly incidents. It is fur -
ther estimated that there will he an increase in the number of malaria cases from
the current 400 million annually to about 500 million annually by the year 2100,
based on the global climate change models and the substantial geographical widen-
ing of the malaria zone associated with a 3°C increase in global mean temperatures.
For example, in southern Honduras, erosion from grazing and farming, coupled with
a severe increase in temperature between 1972 and 1990, forced many Hondurans
into recently deforested regions in the north. The new migrants tended to be non-
immune to malaria. The surge in population, coupled with heavy rains, caused the
number of malaria cases in the northern region to more than quadruple.
Souri: WRJ, 1996. See also McMichael et al,, 1996.
and water vapor, into the earth's atmosphere. The increase in the release of these
gases exaggerates the greenhouse effect (see section The Greenhouse Effect), but
the underlying reason for this increase is intensive industrial and agricultural de-
velopment and increasing consumption of fossil fuels. The rapid rise in concen-
tration of these greenhouse gases is occurring in the troposphere. Carbon diox-
ide is increasing at 0.4% per year, methane at about 1% per year, CFCs until
recently at about 5% per year, and oxides of nitrogen at 0.3% per year; the con-
centration of ozone and a miscellaneous group of other gases is also on the rise.
This increase is mostly the result of industrial and transport development, espe-
daily the use of internal combustion engines and coal-burning electric power
generators. Methane also comes from agriculture, landfills, and other sources,
such as the decomposition of rotting vegetation and from the digestive tracts of
plant-eating animals like cattle. Water vapor, another important greenhouse gas,
has not been increased as much by human activity and does not seem to be ris-
ing (Mungall and McLaren, 1990; National Academy of Sciences, 1992).
Of these greenhouse gases, carbon dioxide is the most important, accounting
for half of the effect. It is also particularly difficult to control, because it is gen-
erated by any form of combustion and is inevitable in the burning of fossil fu-
els. By contrast, the CFCs are no longer increasing in concentration. A world-
wide moratorium on their manufacture and distribution in new products was
negotiated when they were identified as the principal cause of stratospheric ozone
depletion (see section Stratospheric Ozone Depletion, above).

Climate Change and Tick-borne Diseases
Ticks belonging to the Ixodidae family have a wide geographical distribution range,
including parts of the subarctic regions. These ticks are vectors for several diseases,
such as Lyme disease and tick-borne encephalitis (TBE). Several animals, such as
birds, rodents, and deer, act as hosts for the tick. They may be infected with the
pathogen and can pass it on to humans through a blood-sucking tick. Ticks as well
as their host animals and habitat are all dependent on changes in local weather con-
ditions. A future climatic change would affect the complicated ecological interac-
tions associated with the transmission of tick-borne diseases. As a result, tick-borne
diseases may spread into new areas that are located at higher northern latitudes and
altitudes than present endemic regions.
Contributed Lw E. Lindgren, Sweden.
Support for these projections of greenhouse gas accumulation comes from a

variety of sources. Among the most useful are studies of trapped air in glacier
ice and lake sediment. Carbon dioxide concentrations in the atmosphere today
are thought to be the highest in 160,000 years, as judged from trapped bubbles
in Antarctic glacier ice. Methane levels are also much increased in more recent
ice core samples. A close association throughout this period between carbon diox-
ide levels and estimated global average temperature at the time (as indicated by
fossil hiota and carbon isotope concentrations) is discernible in most of these stud-
ies (Mungall and McLaren, 1990; WHO, 1992a).
Carbon dioxide is absorbed by plant life and is thereby removed from the at-
nnosphcre through natural growth and agriculture. A mechanism for relatively
unlimited removal of a chemical from the environment is called a sink. The most
significant sinks for carbon dioxide appear to he in the Amazon rain forest and
the temperate zones of the Northern Hcmisphere, where widespread destruction
of the forests has occurred. The boreal forests in Canada and Siberia may also of
great concern. Deforestation reduces the capacity of the biosphere to remove car -
bon dioxide and to act as a stabilizing mechanism to climate change. Thus, there
is a direct link between global climate change and changes in land use patterns
such as deforestation, as discussed below.
Solutions to the Problem

The solution to the problem of climatic change is deceptively simple but difficult
to achieve: reduce the generation of greenhouse gases, particularly of carbon
dioxide, and increase the capacity of the sink for carbon dioxide by stopping de-
forestation and increasing forest growth (see Fig. 11.6). Although what needs to
be done may seem obvious, it is very difficult in practice to reduce the combus-
tion of fossil fuels and to increase forest growth.

Figure 11.6 The carbon cycle. From McMichacl, 1993, with permission.
Economic growth in modern industrial societies is based on relatively inex-

pensive energy supplies. Regional economies, such as the Middle East, Western
Africa, and North America, are highly dependent on the sale of petroleum and
petroleum products for their stability. Virtually the entire developed world is de-
pendent on oil imports for transportation and energy needs. A reduction in the
dependence on fossil fuels would require extensive energy conservation, creat-
ing economic hardship in many parts of the world. Many rapidly developing
countries are understandably reluctant to agree to limits on the production of
carbon dioxide that would restrict their own economic growth, especially since
they see themselves as needing to catch up with the developed countries that
caused the problem in the first place. At the same time, oil supplies are limited

worldwide, so extensive conservation would have the effect of expediting by one
generation or SO the inevitable depletion of petroleum reserves. However, many
nations are counting on revenue from oil in the short term to build the infra-
structure of a stable economy that will continue after the oil runs out. Thus
progress toward a negotiated reduction in greenhouse gas emissions has been
much slower than that for controlling CFCs (WHO, 1992a).
DEFORE STATION AND DE SERTIFICATION
Human activity has changed the face of the earth considerably. Only remnants
now remain of the huge forests that once covered Europe, the Middle East, and
China. Central Europe was once a dense forest and in Roman limes the cedar
groves of Lebanon were famous. North America used to be much more heavily
forested along the East Coast than it is tcday, although the forest is coming back
in many areas of the East Coast. Large tracts of forest remain in protected areas
in North America, in the mountains of the West, along the Pacific Northwest,
and in the far North. Southeast Asia, South America, and Africa still have vast
expanses of rain forest but through the clearing of huge areas for agriculture and
industrial development, the total area of forest coverage has been rapidly re-
duced.
Clearance is usually undertaken on a piecemeal basis for agriculture. Often,
as in the Amazon Basin and Indonesia, woodlands are cleared by fire. Some-
times, as in northern Africa and China, forests are consumed for firewood. The
resulting depletion of forests can result in serious ecological consequences.
Forest Eco.svstem Changes

Woodlands protect the soil on which they stand in many ways. Root systems and
ground cover slow down the passage of water through the ground and keep soil
in place. Forest debris and ground cover recycle nutrients and provide lood for
wildlife. Trees and fallen trees provide shelter and habitat for wildlife and reduce
the impact of strong winds.
In general, forests tend to be cooler and more humid than arid country and
provide a much greater diversity of ecological niches in which wildlife may flour-
ish. This is particularly true at the edge between forests and open land and be-
tween forests and wetlands, where the complicated interface supports great di-
versity. In tropical rain forests, soils tend to he acidic and relatively poor in
nutrients but the forest and its debris support many forms of life. In northern or
boreal forests, growth tends to be very skw because of the cold weather, and
the less diverse wildlife tends to experience great cycles of population growth
and decline.
When woodlands are cut down and cleared, these complicated natural sys-
tems are lost and arc replaced by a much simpler, artificial environment that is
mttch less stable ecologically and much less productive biologically, although
there may be short-term economic gain. In arid regions and when the destruc-
tion of the forest is too extensive, the ability of the forest to recover is lost. In
some places, the cleared foirest may return to scrub brush whereas in other places
soil changes and loss of ground cover may create a desert where lorest existed

before. This latter procs is called desertification and it has been a particular prob-
1cm recently in northern Africa. Desertification happened long ago in many parts
of the Middle East and areas that are now very dry were once wet and heavily
forested.
Erosion by wind and water is much more severe when woodland and brush
cover are removed. Unprotected soils are carried into streams and rivers, where
silt affects fish stocks and clogs small channels. Soils newly available for agri-
culture can be rapidly depleted once the forest cover is removed; this is a par-
ticular problem in the tropics where certain types of soil become hard when
the ground cover is removed. Nutrients in the soil can also be leached out by
the rapid passage of water through the topsoil. Wind may be much harsher in
human settlements without the protection of a woodland windbreak and there
may be local climate changes when the moderating effect of the forest is re-
moved. Habitat for wildlife is destroyed and along with it the stability of the
local ecosystem. This leads to the degradation of lands that could attract mixed
uses, such as grazing, hunting, tourism, and wood harvesting. Biodiversity is
much reduced (as described below) and with it, much of the economic poten-
tial for the region. Agriculture introduced into areas of deforestation may lead
to a single-crop economy and dependence on world or regional commodity
markets.
Forest Ecosystems and Global Change
Forests also play a critical role in the removal, storage, and release of carbon
dioxide from the atmosphere, as discussed earlier. Throughout history, at least
since the last Ice Age, it would appear that the global sinks for carbon dioxide
have had sufficient capacity to absorb any excess caused by volcanic eruption or
forest fires. As a result, the content of carbon dioxide in the atmosphere remained
relatively stable. Today, however, production of carbon dioxide exceeds the ca-
pacity of the global sinks, and the concentration of the gas in the atmosphere is
steadily increasing, leading ultimately to the exaggerated greenhouse effect de-
scribed above (see McMichael et al., 1996).
Defcrestation reduces the capacity of the world's forests to serve as a carbon
dioxide sink. Burning forested areas aggravates the global accumulation of car-
bon dioxide in the atmosphere. When forests are cut down for firewood or catch
on fire, the stored carbon in the wood and brush is released into the atmosphere
again. Even when wood is used for building construction and other purposes,
some carbon dioxide is eventually released. Another, and quite unexpected, con-
sequence of deforestation is mercury contamination, as described in Box 11.5.
Reforestation, on the other hand, takes carbon dioxide out of the atmosphere
and traps it in biomass. That is why one response to the challenge of global cli-
mate change has been to encourage the planting of trees and the reforestation
of forests.
As mentioned in the section Solutions to the Problem, the most significant
sinks for carbon dioxide appear to be in the Amazon rain forest and the tem-
perate zones of the northern hemisphere. Large-scale destruction of the Ama-
zonian forests and, potentially, the boreal forest in Canada and Siberia will re-
duce the capacity of the biosphere to remove carbon dioxide and act as a

BOX 11.5
Mercury Contamination in the Amazon: Effects of Gold Mining
and Deforestation
Gold mining in the Amazon, originally thought to he the only cause of the mercury
pollution of some of the rivers, began approximately three decades ago when thou-
sands of impoverished miners, known as garimpeiros, swept into the jungle to mine
gold using a mercury mining method they use to this day (see Chapter 10). About
half of the approximately 130 tons of mercury per year used is emitted into the air
while the other half seeps into the water, contaminating fish.
The team of Canadian and Brazilian scientists investigating the mercury conta-
mination and its health effects on the villagers (see Lebel et al., 1995) began to sus-
pect that there was too much methylmercury in the Amazon to be the result solely
of garimpeiros activities. Everywhere they collected river sediment samples they
recorded 1.5 to 3 times more mercury than there had been 40 years ago, even 400
kilometers downstream from the gold mining. They soon found that deforestation
was the other source. When impoverished people from northern Brazil colonize the
Amazon jungle they usually clear the forest in a 10 to 20 kilometer area on both
sides of a river and burn the remaining rubble. Following deforestation, heavy rains
wash out nutrients from the soil into the waterways. As the Amazon basin has con-
siderable natural mercury in its soil, mercury released into the water contaminates
the fish to cause mercury poisoning in people consuming large quantities of fish.
The Canadian team had a particular interest in mercury because in the north-
ern area of two Canadian provinces, high mercury exposure occurred in the abo-
riginal community from a similar process: hydroelectric dams and reservoirs raised
water levels, the water inundated ancient soils, which then degraded and released
their naturally occurring mercury.
Although Brazil has officially banned the use of mercury for mining, this tech-
nique is still occurring. Moreover, the reforms instituted have not added the prob-
lem of landless settlers burning trees and destroying the soil, thereby releasing mer-
cury into the Amazon. In the meanwhile, in discussing the results with the
community, it was advised that they vary their diet so as to eat more "fish that do
not eat other fish."
Contributed by D. Mergler
stabilizing mechanism to climate change. Thus much attention has been given to
the development of the Amazon Basin and concern expressed over the clearing
of rain forests in South America and the northern hemisphere (Canada and
Siberia). Not surprisingly, the few countries with large forested areas remaining
have been singled out for criticism, notably Brazil. This issue has led to a con-
flict over the right of a particular country to pursue its short-term development
strategy and the right of the world as a whole to be protected from massive
change in the long term that will affect everyone. Forests in many parts of the
world, such as Brazil, are being cleared in remote areas for agriculture and eco-
nomic development by people who have limited economic opportunities and are

not easily policed by their governments. Although it seems clear that deforesta-
tion may be a poor economic strategy in the long term, it provides needed jobs
and agricultural productivity in the short term for local residents. There has been
little success in changing deforestation practices on a local level because of the
lack of alternatives available to these people.
Reducing deforestation and increasing forest growth are difficult to achieve.
Some countries have had success in preserving their forests while increasing
economic opportunities through so-called debt -for-equity swaps. In these deals,
countries with large debts may have some of the debt forgiven or refinanced
at a lower rate in exchange for restricting access to and development of eco-
logically critical areas like forests. The problem with such programs is that the
country loses some control over its economic future, although it does reduce
its accumulated debt. Other countries, such as China, have had success with
massive reforestation programs to restore woodlands in areas that have been
badly depleted.
B IODIVER SITY
Biodiversity refers to the multiplicity of species of plants and animals in a biolog-
ical community and the many ecological niches that they may occupy. It is a
fundamental principle of ecology that diversity in animal and plant species leads
to greater stability of the ecosystem. The ecosystem functions more efficiently,
with different species occupying more niches and extracting full benefit from the
energy and nutrients available. More complicated systems have greater adapt-
ability in the face of environmental changes and the ecological niches occupied
by different species may partly overlap and allow substitutions if one or more
are lost. Loss of biodiversity therefore means a less stable, less adaptable, less self-
restoring ecosystem (Chivian et al., 1993).
Biological Siqnificance of Biodiversitv
Biodiversity is also a means of preserving genetic diversity. Each species and sub-
species contain within their genes the result of hundreds of thousands, even mil-
lions of years of evolution. This genetic constitution is written onto DNA, the
molecule that conserves the genetic code. It constitutes a library of 'blueprints'
for living beings and for biological adaptation. For all groups of organisms rec-
ognized as species, there is a basic genetic constitution consisting of characteris-
tics common to all members of the species, and a set of variations that have been
introduced by mutations, random changes in the gene pool introduced by mis-
takes in replication of DNA or the effect of ionizing radiation on DNA. Most of
such mutations are harmful and do not survive; a few confer new traits that may
or may not be useful to the individual that carries them. The variation in ge-
netically determined traits among individual members of any species or subspecies
is what drives evolution: natural selection favors some variants and not others,
SO that some traits survive and others do not. Many of the variants represent
traits that survived because they were useful; the individuals who carried the
traits could adapt to new conditions or exploit new ecological niches. Loss of bin-
diversity means that even if the species as a whole survives, the variation within

the species is reduced, making it less adaptable and, in effect, stopping its evo-
lution (Chivian et al., 1993).
Economic Aspects of Biodiversity
Much of the diversity among species and subspecies and many of the variations
among individuals within a species have direct practical uses to human society.
They have been the basis for developing all agricultural crops and breeding all
livestock, for example. Biodiversity is reduced in agriculture in the long run as
certain strains are chosen for their greater productivity, resistance to pests, or
ability to grow with less water, for example, and these strains are selected or hy-
bridized to existing strains. The new strains are then planted as a monoculture, a
uniform stand or herd of genetically similar or even identical organisms. This
monoculture tends to be very susceptible to new pests or diseases to which it is
vulnerable. Once it is infected, the entire stand or herd is at risk because there
is no native resistance. The monocuhure is also bred for a particular environ-
ment and when the environment changes, as, for example, during a drought, it
is unlikely to adapt. Sometimes, genetic traits that would have conferred resis-
tance or that would have allowed adaptation to a changing environment were
present in the wild strain but have been lost through selective breeding for other
characteristics. For this reason, scientists try to maintain biodiversity in the lab-
oratory by keeping seed stocks and cultivating representatives of genetically un-
usual plants to ensure that they are not lost.
Among the many forms of biodiversity is the variation among species and
subspecies in synthesizing unusual chemicals. Snake vcnoms, pheromones that
attract insect mates, squid ink, and the light-producing chemicals of fireflies are
just a few examples. Plants, especially, produce a wide variety of novel chemi-
cals for special purposes, such as to protect themselves against insect pests. Many
of these chemicals have unusual properties that may or may not be related to
the advantages they confer on the plant or animal. Medical researchers take ad-
vantage of this diversity by identifying chemicals produced by plants and animals
that have a biological effect and turning them into useful drugs. With loss of bio-
diversity, a huge reservoir of potentially useful chemicals may be lost that could
be found in no other way (Chivian et al., 1993).
The search for economically useful biological products that become available
because of biodiversity has been called hioprospecting. One of the more important
methods of bioprospecting has been to use the knowledge of indigenous peoples
who have used herbal remedies and natural products for millennia and who have
accumulated over time a deep understanding of their effects through experience.
The ethics and economics of sharing the benefits of bioprospecung and produc-
tion with the indigenous peoples who passed on the knowledge have become
major issues in recent years. The future economic development of many of these
peoples, and their control over their own culture and development, may rest on
how this issue is resolved.
In biotechnology, methods of genetic engineering are being used to select
genes directly for new product development. Because of biodiversity, biotech-
nologists have an essentially unlimited library of genes from which to construct
new materials. However, genetic engineering may also accelerate the process of

developing monocuhures, by allowing agricultural scientists to be even more se-
lective in choosing the specific traits they want while overlooking seemingly less
important traits (WHO, 1992a).
Loss of Biodiversitv
Ecosystems can lose hiodiversity in many ways. Individual species may become
extinct through hunting, habitat loss, or reduction in the species that they de-
pend on for food. Entire ecosystems or large areas of larger ecosystems may he
changed or lost by urbanization and agricultural clearance. Particular habitats of
individual species with limited ranges may be lost in the same way: the essen-
tial area lost might relate to feeding requirements, territoriality, or breeding.
Sometimes foreign species are introduced into a stable ecosystem, preying on and
reducing the numbers of the local species that give the ecosystem stability. Of-
ten all of these mechanisms occur at the same time (Chivian ci al., 1993).
Even ecosystems that appear to be healthy may suffer loss of biodiversity.
Old-growth forests, for example, are forests that have not been cut down and
that maintain a much richer diversity of species and considerably more stable
ecosystems than new-growth forests, which arise by ecological succession after
earlier forests have been cut down. Even though the forest may look the same,
appearances can be very deceiving.
Loss of biodiversity is an important indicator of the magnitude of these trends.
It shows the extent to which the ecosystem is being simplified. Because the sta-
bility of ecosystems depends on complexity and variability, simplification is nec-
essarily environmental degradation, regardless of what else is happening in the
environment. That is why it is a mistake to concentrate too narrowly on the eco-
logical or economic importance of a particular species when it comes to local is-
sues of conservation and ecosystem protection. The loss of a particular species or
subspecies is important in and of itself, but it is also another thread that is cut
in the ecological web and reflects a trend toward an increasingly simplified and
unstable ecosystem. Biodiversity is a critical part of the network of ecological re-
lationships that supports human society. Loss of biodiversity is both a serious
problem in its own right and a sensitive sign of the deterioration of the envi-
ronment as a whole.
ACID PRECIPITATION
Acid precipitation (acid rain) occurs when rainwater, snow, and other forms of
precipitation have a lower than natural pH as a result of dissolved acidic chem-
icals that occur from air pollution. This is caused by increased production of acid-
ifying emissions from industrial sources, principally sulfates and nitrates, and air -
borne transport of these pollutants. Often, these pollutants are carried very long
distances and fall as acid precipitation hundreds or even thousands of kilometers
away from the original site of production. When the precipitation reaches the
ground, it can change the pH of small lakes and the soil, causing ecological dam-
age. This is particularly a problem in areas where there is little natural buffering
capacity in the soil or water (WHO, 1992a).
In recent years, surveys of soil and water acidity in the Northern Hemisphere

have shown increased acidity (or, more accurately, reduced acid neutralizing ca-
pacity) and presumably irreversible changes in pH in soils. The problem has been
most severe and most heavily documented in Canada (largely as a result of emis-
sions from the U.S. Midwest) and Scandinavia (from emissions arising in Ger -
many and Britain). The situation in Russia and Eastern Europe is still being as-
sessed. Similar processes are probably occurring in China, India, and Central Asia.
The result has been extensive changes in the biology of small bodies of water.
Acid precipitation is highly detrimental to delicate aquatic ecosystems, marine
biota, and some terrestrial species of plants and trees. It is blamed for severe and
widespread effects on forests in Scandinavia and Germany in particular (Berdén
Ct al., 1987; Mungall and McLaren 1990; WHO, 1992a; Chivian ci al., 1993).
Direct effects of acid precipitation on humans have been difficult to study.
Transregional transportation of pollution, as with acid deposition and the long-
range transport of air toxins, may result in increased airway reactivity and asthma.
Asthma has been observed as a result of increased levels of acidic chemicals, such
as sulfates, in the air in southern Canada (Franklin et al., 1985). Some authors
have speculated that if metals are leached into groundwater at excessive con-
centrations, there may be toxic effects, but this is not yet proven (Goyer ci
al.,1985).
The obvious control strategy for acid precipitation is to reduce the generation
of air pollutants at the source. A particularly important step would be to reduce
the consumption of fossil fuels in producing energy. Not every country agrees
with the scientific analysis of the problem nor is every country willing to curtail
its own economic development by imposing regulation or decreasing production.
A major technical problem is the consideration of control strategies for acid pre-
cipitation without having a clear understanding of loading capacities, i.e., the
maximum emissions that an ecosystem can absorb before its capacity to neu-
tralize, transform, or dilute the pollutant is exceeded. Such information has been
estimated for regions in northern Europe but is not available for most parts of
the world (Berdén et al., 1987).
TANSBOTJNDARY MOVEMENT OF HAZARDOUS WASTE

Toxic and hazardous chemicals are increasingly mobile in today's world. Not only
are they being shipped around the world as commodities for various purposes in
production but also chemical and radioactive wastes are being moved about as
concern grows about proper storage and handling. In the developed world, it is
becoming increasingly unacceptable to local residents to permit the storage or
disposal of hazardous waste. In many developed countries, the options for get-
ting rid of such wastes are disappearing. Hazardous waste disposal sites are clos-
ing because of community opposition, and chemical treatment facilities are be-
coming increasingly costly because of ever more stringent measures to protect
the environment. It has been estimated that approximately 400 million tons per
year of hazardous waste cross international boundaries, much of it being illegally
moved to unauthorized disposal sites. The result is that unscrupulous parties are
often tempted to ship hazardous material to countries where environmental reg-
ulations are more relaxed and enforcement is not as strong. The receiving coun-

TABLE 11.2
PROVISIONS OF THE BASEL CONVENTION
I. The generation and movement of wastes should be reduced to the minimum required and the
wastes disposed of as close as possible to the site of origin.
Every country has the right to ban importation of hazardous wastes, and signatory countries
shall not allow transhoundary movement of hazardous waste to any country that has banned
its importation, whether a signatory or not. Also, signatory countries will not allow the export
of hazardous wastes if there is a reason to believe that they will not he disposed of in an appro-
priate and environmentally safe manner.
Signatory countries will not allow hazardous wastes to he imported from or exported to
nonsignatory countries unless their movement is governed by agreements that are at least as
strict as the Basel Convention.
The exporting country will not allow the hazardous waste to leave until it has written confir-
niation of consent on the part of the importing country and any cortntry of transit, reflecting a
decision based on knowledge of what the shipment contains.
When the hazardous waste cannot be safely transported or handled, the exporting country has
a dttty to take it back.
Anything that does not conform to these prmciples is considered illegal tratlic, to he pttnished
by criminal sanctions that each signatory country must develop and legislate.
tries are often willing partners because of the money the importation of haz-
ardous waste brings in the form of fees, facilities, and, sometimes, bribes. How-
ever, these countries usually have no effective means of controlling hazardous
waste once it arrives. In some cases, the waste is simply dumped where it may
pollute groundwater, the oceans, or land. In a few cases, the wastes may be chem-
ically treated and disposed of in a manner that is similar to good practices in the
developed world but without the stringent supervision and monitoring that is
needed to ensure that the material does not pollute the environment.
Such practices are not confined to the developing world. Some of the worst
incidents documented recently have involved the former East Germany and the
former Soviet Union. Developing countries arc particularly vulnerable to this
form of "toxic blackmail." Since 1989 an international protocol on the move-
ment of hazardous waste, the Base! Convention, has governed the transboundary
movement of hazardous wastes, on the basis of the six principles paraphrased in
Table 11.2.
DISASTERS
By definition, disasters involve many casualties occurring in a short period of

time, following an unusual event. They may be natural or the result of human
activity. The emphasis in modern times in responding to disasters is on disaster
planning and preparation. A complete discussion of disaster preparation is be-
yond the scope of this text.
Emergency Actions
Depending on the magnitude of the disaster and its extent, disasters can overwhelm
the health care system in the area and disrupt the operations of fire, transporta-
tion, and rescue services. In the first few hours following a disaster, the first prior-

ities are to identify and provide medical care to the injured, locate and rescue miss-
ing persons, and identify and control physical hazards, such as ruptured gas lines.
In the case of chemical or radiation incidents, decontamination is a high and ur-
gent pricrity to prevent further exposure. Subsequently, the provision of basic ser -
vices, including shelter, food, potable water, sanitary facilities such as latrines, and
psychological intervention become an urgent priority if the disaster has disrupted
services in the community. Burial of the dead, provision of warm clothing, and
evacuation of the injured or vulnerable may become health priorities, depending
on circumstances. The risk of infectious disease increases in the days following the
disaster, as water supplies may be interrupted and sanitation becomes an increas-
ing problem. Over the long term, rehabilitation and reconstruction become in-
creasingly important as the community comes to terms with the devastation.
Natural and Technological Disasters

Disasters are of two general types, and the responses of communities tend to dif-
fer with each type. Natural disasters occur as a result of the action of natural forces
and tend to be accepted as unfortunate but inevitable. Technological disasters oc-
cur as the result of some human activity and tend to be deeply disturbing to a
community, leading to the blaming of culprits and a sense of shame in the com-
munity. Chapter 4 discussed factors that affect risk perception; similarly, the re-
sponses to natural disasters tend to be very different from those to technological
disasters (see Table 11.3). Each are discussed in dctail, below.
Natural disasters result from natural forces of climate and geology. Although
there is often a history of such disasters in a given area, natural disasters are usu-
ally unpredictable in the short term. The circumstances preceding the actual event
may make the disaster much worse than it had to be. For example, extensive
building on an earthquake fault or on an exposed shoreline subject to storms
may greatly increase the casualty rate from an otherwise moderate event. Build-
ing with inadequate materials and failing to provide access to evacuation or emer -
gency services routes may greatly complicate the rescue effort. The rescue effort
may be inadequate or poorly organized; if it is delayed by more than a few hours
in a major disaster, the responsible agency often comcs under heavy criticism.
The reconstruction effort may be prolonged, poorly coordinated, and complicated
by bureaucracy, often leading to great public dissatisfaction, even if the immedi-
ate response to the disaster was received with gratitude.
Natural disasters that result from climate, such as hurricanes, tornadoes, and
flooding due to prolonged rains, tend to cause more property damage than deaths.
TABLE 11.3
PERCEIVED DIFFERENCES BETWEEN NATURAL AND TECHNOLOGICAL DISASTERS
Natural Disasters Technological Disasters
Nature of disaster Clean, unavoidable Dirty, contaminated
Responsibility No agent Culpable party
Objective magnitude of loss Often great Usually less
Perceived magnitude ol loss Usually minimized Usually maximized
Community support for those affected Nonjudgmenta] - Highly judgmental, ambiguous

They are profoundly demoralizing to the people displaced from their homes, but
the community affected tends to respond quickly, and the long-term conse-
quences are often less than one would expect. These are relatively familiar haz-
ards, are easily understood, and are often common enough in the area affected
to be thought of as a fact of life. Disruption of sanitary facilities and transporta-
tion tends to be less severe than in other types of natural disasters, except in the
case of flooding. A severe storm is clearly terrifying and threatening, but com-
munities tend to handle this type of disaster more easily than other types.
Natural disasters that result from geological activity, such as earthquakes, vol-
cano eruptions, mud slides, tsunamis (seismic tidal waves), and flash floods (in-
volving sudden rainfall in terrain that funnels it into swiftly flowing channels),
tend to result in more casualties than those due to climate and may severely dis-
rupt the ability of the community to take care of its own needs in the hours and
days folk wing the event. Forest fires share many of these characteristics. In both
kinds of disasters, there are often many missing persons and trapped victims who
require rescue. The type of injury is usually more severe, reflecting the risk of
collapsing buildings and the massive forces involved, and may lead to serious
public health problems even when adequately treated. Psychological stresses as-
sociated with the event appear to be greater than for disasters related to climate,
and affect both victims and rescuers.
Technological disasters result from some human activity such as explosions,
the release of toxic chemicals or radioactive material, bridge or building collapse,
fires, and crashes. Technological disasters tend to involve many more casualties
than natural disasters of the same magnitude of energy release. They are also
much more difficult for the community to deal with and for victims to accept.
The psychological factors that influence perception of technological disasters are
very different from those for natural disasters. In technological disasters, there
are issues of blame involved and the community spends much time discussing
who was responsible and what mistakes were made. Olten there are complicated
lawsuits, investigations and claims for disability involved. If there was previously
a feeling that the owners of the facility responsible were abusing the community
or making excessive profits, this adds to the fury of the community's response.
Sometimes victims are shunned by their neighbors, who feel that they are ex-
ploiting the situation for personal gain or who are fearful that the response to
the incident will cause economic loss to the community. As a result, technolog-
ical disasters tend to divide the community and to cause long-lasting psycholog-
ical trauma to local residents as well as to victims. Examples of major techno-
logical disasters in recent times include the release of toxic methyl isocyanate gas
in Bhopal, India in 1984 and the explosion and release of radiation from the
Chernobyl nuclear reactor in the Ukraine in 1986. Incidents on a much smaller
scale are not rare but do not get as much attention.
An important exception to the generalizations made about natural and tech-
nological disasters above is drought. Drought is related to climate and is relatively
slow to develop. The primary public health consequence of drought in less de-
veloped regions, where food cannot be easily imported, is famine. Casualties from
starvation may be very high, as in the prolonged drought in Sub-Saharan (Sa-
helian) Africa where around 1970 over 200 million people were estimated to

have been affected. In addition, drought and famine may cause extensive, long-
lasting social tensions because they act to deepen poverty very suddenly and di-
vide society between those who can afford to get food at any price and those
who cannot. Drought and famine are also associated with large population move-
ments that complicate the task of providing medical care, food, and water to the
affected communities. Thus, the combination of drought and famine is one type
of natural disaster related to climate that has many of the worst characteristics
of technological disasters.
Psychological Effects of Disasters on Survivors

Psychological symptoms following disasters tend to be similar among children,
but among adults they are somewhat more complicated and variable. Children
are often fearful and show disproportionate anxiety over separation from their
friends or parents. They may lose motivation, act in rebellious ways, and begin
to do poorly in school. Children often respond well to immediate mental health
interventions aimed at helping them to express their feelings and fears about the
event. Adults are often able to cope reasonably well during the event but may
fall apart afterward; a small minority will become incapable of acting during the
stress of a crisis and will have to be forced to move. Adults who survive a disas-
ter may experience a range of adverse effects, such as nightmares, uncontrollable
thoughts that involve reliving the events, trouble sleeping, no emotion, and a
sense of detachment from the other people in their lives and the world in gen-
eral. In adults these symptoms are characteristic of post-traumatic stress syn-
drome. Adults may also he helped by mental health professionals who discuss
with them as a group what happened and what their reactions are, a process
known as critical incident debriefing. Part of what is helpful about this process is
the reassurance that these feelings are natural and that those affected are not
mentally ill. Rescue personnel often have the same symptoms and feelings as
survivors and victims, and may also benefit from critical incident debriefing. While
there is some questioning of the value of psychological debriefings in preventing
posttraumatic stress disorder (Bisson Ct al., 1997), most authorities do recom-
mend it when appropriate (Mitchell and Evans, 1999).
Mutual assistance and disaster intervention programs may significantly limit
the impact of a disaster on the community. International assistance is difficult to
manage and coordinate but may make a decisive difference in the outcome, es-
pecially in countries and areas with very limited resources.
GLOBAL CHEMICAL CONTAMINATION

The problem of global chemical contamination due to ozone layer depletion was
described earlier in the section Ozone Depletion and Ultraviolet Radiation. In this
case, the offending chemicals, the CFCs, have no direct impact on human health
occurring during their use, but they are very persistent, dispersing into the at-
mosphere, and eventually reaching the stratospheric ozone layer, where they re-
act chemically with ozone. The resultant reduction in ozone concentration reduces
the blocking effect on UV radiation of the ozone layer and increases the UV radi-
ation that reaches the surface of the globe. As already discussed, the increased UV

exposure at ground lcvel effects both humans and ecosystems, some of these ef -
fects are extremely important for agricultural and fisheries productivity.
Another issue that has been given increasing attention is the use of chemi-
cals that persist for long periods of time in the environment; the possibility ex-
ists that a buildup of these chemicals may eventually affect human and ecosys-
tem health. A well-known warning about this problem was sounded already in
the 1960s in the book Silent Spring (Carson, 1962). At that time, one of the main
concerns was about the effects of DDT and other chlorinated hydrocarbon pes-
ticides. Adverse effects on birds had been clearly demonstrated, but those on hu-
mans at the relatively low exposures occurring in the general environment were
not demonstrated. Recently it has been shown that some of these pesticides have
estrogen-like effects on experimental animals, and links have been made to hu-
man breast cancer and sperm damage, possibly leading to male infertility (see
Chapter 2). DDT is now banned from use in all developed countries, but some
developing countries still produce and use this pesticide, as it is the cheapest and
most cost-effective means of killing certain important insects, such as malaria-
bearing mosquitoes and locusts. There is evidence that DDT and other persistent
organic pollutants (POPs) evaporate into the air in the tropical countries where
they are used, get transported via winds to the colder latitudes, and eventually
get deposited in these colder countries via rainfall. This transfer of pollutants may
create a situation in which the eventual buildup of these chemicals is highest in
the colder countries where they are not used directly.
Study Oliestions
Your health minister has been invited to attend a special cabinet meeting
to discuss your country's response to recent reports regarding climate change.
She has been told that there are no major health impacts in your jurisdiction,
therefore it is not necessary for her to prepare a detailed report. She has asked
you if you think that she ought to attend. Formulate a memo of no more than
two pages offering her advice. Discuss how global warming could affect health
in your country.
What are the most serious global health concerns? Prioritize and justify
your list.
Summarize the areas of greatest debate and state why these debates exist.
What are the obstacles to overcome in addressing global health problems?
What strategies exist to address these obstacles?

12
ACTION TO PROTECT HEALTH
AND THE ENVIRONMENT
LEARNING OBJECTIVES

• describe the actions that can be taken by environmental health profes-
sionals to address environmental health problems
• apply the notion "think globally and act locally" to a specific situation
• understand the important ethical principles involved when taking action
on environmental health issues
CHAPTER (ONTENJTS
From Knowledge to Action Public Education and Capacity

Ethical Principles That Guide Action on Building
Environmental Health Personal Example
Advocacy
Role of Environmental Health Networking
Professionals Research and Documentation
Technical Expertise
Professional Practice
FROM KNOWLEDGE TO ACTION

It is often difficult to reach agreement on the root causes of environmental
problems because different cultures and individuals often hold very different
opinions regarding the causes of these problems. One society may see the prob-
lems as arising from technological arrogance, the attitude that human beings
can do all things without fear of consequences. Another society may see the
problems as representing a moral failure on the part of government and soci-
ety and a desire by individuals to live easily without hard work. Yet another
society may see these problems as inevitable, as part of the costs that must be
paid to achieve a decent lifestyle and to get out of poverty. These ideas about
cause are not necessarily right or wrong, but they cannot be proven and Iro-
vide little practical guide for action. It is usually more productive to concen-
trate on what the problems are today and what actions are needed to keep
them from getting worse.
399
What is not so clear is what to do about them. Many individuals and many
political groups have their own ideas about radical changes that would correct
specific problems at what they perceive to be their root causes. However, the
root cause for some people (for example, overpopulation) may be seen as a sec-
ondary phenomenon by others (as, for example, the lack of education and em-
powerment of women). Radical solutions are easy to conceive but very difficult
to implement. It is clear that the world does not have much more time to de-
bate these issues before the damage to the environment will be permanent, ir-
reversible, and sufficiently advanced to constrain the life choices and freedoms
of the next generation. Regardless of their view of the causes of the problems,
however, many thoughtful and conscientious people are arriving at a common
point of view regarding the most urgent changes that are needed to give society
and the environment breathing room. At least the outline of a consensus is emerg-
ing in countries around the world on the minimal steps necessary to deal with
the issues. These are summarized in Table 12.1, not necessarily in any order of
fundamental importance.
If there is an emerging consensus on the minimum that must be done, the next
question is who should do it. Clearly, many of these actions have a practical, tech-
nical component that must be handled by trained professionals. However, these pro-
fessionals cannot act in isolation. There must be support from the people who are
directly affected, from national leaders, from institutions, and from leaders at the lo-
TABlE 12.1
COMPONENTS TO ADDRESSING ENVIRONMENTAL HEALTH CONCERNS
Pollution control, to prevent the release of pollution into the environment in the first place, and the
economic and regulatory structures that support vigilance in pollution control
Remediation, to clean up polluted areas and to restore them to the extent feasible to their nat ural
or at least an acceptable state
Resource conservation, including recycling and reuse, to reduce the amount of raw materials needed
by industry and increase the efficiency of use of these resources
Ecosvcteoi conservation, to ensure that habitats for the world's species will be preserved in full pro-
ductivity and that appropriate human uses can be sustained
Cenintitnient to end extreme povi'rt'c and support of national efforts to achieve a sustainable ec000nly,
to provide for most of the world's peoples at least a comparable level of economic security and
personal wealth to that in the developed world today
Technology transfer, to allow the developing world to industrialize with the advantage of the more
efficient, less hazardous, and less polluting technologies
Sustainable economic systems that base their economic productivity on what can be extracted from
the environment without permanent damage over the long ternl
Control of population growth, with a concomitant commitment to improved quality of lamily life and
individual security
Acceptance of some deqree of risk as part of daily life, along with a ommittnent by society to moderate
the effects of risk on its citizens throttgh education, regulation, and economic incentives so that
the hazards of life are not constant preoccupations
Prevention of conventional and nuclear war to the fullest extent that ho ma ii institutions can manage,
and the redirection of funds spent for armaments for peaceful purposes, including environmen-
tal reconstruction

Cal level who are perhaps most influential of all in determining whether reforms can
be incorporated into the daily life of commerce and social interaction. Forming al-
liances with community leaders, elders, or traditional healers is essential. For this rea-
son, among others, environmental health professionals cannot be just technical ex-
perts. They must also serve as agents of change within their society, educating people
about the importance of these issues and mobilizing others into effective action.
ETHICAL PRINCIPLES THAT GUIDE ACTION

ON ENVIRONMENTAl, HEAlTH
The environmental health professional must make many decisions in daily work
that involve not only technical-scientific issues but also issues of ethics. The ba-
sic ethical principles in environmental health work follow the same ethical prin-
ciples as have been developed for other health work, except that these guide-
lines ask environmental health professionals to pay even greater attention to the
broader social consequences of their work. Table 12.2 provides the ethical guide-
lines that have been developed for environmental epidemiologists. They apply to
other members of the environmental health team as well.
At the personal level the application of ethical principles involves how one's
own lifestyle and resource consumption reflect the environmental health con-
cerns that have been outlined in this hook. Ultimately, every environmental
health professional must strike a balance between his or her own convictions
and personal commitment and what is required to be professional. Some useful
guidelines are shown in Table 12.3.
In the broader global context, the environmental health professional also has
responsibilities in promoting and facilitating community application of a precau-
tionary environmental health approach. As a member of an interdisciplinary
team, strengthening one's specialized knowledge in one's own profession will
help contribute to the solution of environmental health problems. The following
section outlines these roles more specifically.
ROLE OF ENVIRONMENTAL HEALTH PROFESSIONALS

Environmental health professionals are the repository of technical expertise in a
society and the first resource consulted for technical advice on how to deal with
environmental health problems. Such professionals must adopt different roles in
interacting with different groups and in diflerent situations; one approach will
not work all the time or in all situations. This means that environmental health
professionals must understand their various roles thoroughly and achieve the
skills required to be effective in these different roles.
Technical Expertise
The first and most obvious role of the environmental health professional is to
master the technical details and context of environmental problems. In order to
solve a problem, it is usually necessary to understand what caused it, and it is
always necessary to understand what perpetuates it. This textbook will help
achieve this level of mastery, but it is not sufficient in and of itself. Further de-
ACTION TO PROTECT HEALTH AND THE ENVIRONMENT 401

TABLE 12.2
ETHICAL GUIDELINES FOR ENVIRONMENTAL EPIDEMIOLOGISTS
OBLIGATIONS TO RESEARCH PARTICIPANTS
Respect the rights and personal autonomy of all

Advise of both individual and collective benefits and harms from proposed research
Protect their welfare
Obtain informed consent whenever feasible
Protect privacy/maintain confidentiality
Use data and specimens for only the purpose(s) that consent was provided
OBLIGATIONS TO SOCIETY
Avoid partiality
Distinguish one's role as scientist from that of advocate
The public interest always lakes precedeisce over any other interest
Be objective in disseminating research findings and he understandable in public discussions
tnvolve communities being proposed for study throughout all stages of the research and its
rep i rt ii g
Engage with other disciplines to advance and maximize the public utility of environmental
epidemiology
Consider the broader social consequences, including psychosocial and physical health outcomes
Consider both eqenty and remediation in the allocation of resources applied to environmental epi-
demiology research across the different areas of research, social strata, and jurisdictions
Environmental epidemiology findings arc based on uncertainty and as such must he used appro-
priately in their application to, for example, the development of risk analyses, policy, and
interven I ions
Be diligent in exectiting professional responsibilities
OBLIGATIONS TO SPONSORS AND EMPLOYERS
Ensure that both researcher and sponsor/eniplover are apprised of one another's respective re-
sponsibilities and expectations
Emphasize obligations to other parties
Protect privileged information, but release research methodv procedures and results
OBLIGATIONS TO COLLEAGUES
Promote rigor in research design and neutrality in the execution of research

Report and publish methods and results in the peer reviewed litcrainre of all studies, I egardless of
whether the findings arc positive or negative or have no effect
Confront unacceptable behavior and conditions
Communicate ethical requirements
OBLIGATIONS ACROSS ALL THE ABOVE-NAMED GROUPS
Consult with stakeholders, incltiding community members

Avoid conflicting interests and partiality
Pursue responsibilities with due diligence
Communicate findings in publicly understa ndahle ways
Source ,Soskolne a id Ligli I, 1996.
veloprncnt of knowledge and skills will be required. In fact, the learning process
continues throughout one's professional life. This process will be more effective
if every problem faced is seen as an opportunity to understand better how to
solve the next problem. To become an effective professional in this field, one
needs to keep up-to-dale with the technical-scientific knowledge, as well as de-

TARIE 12
ETHICAL PRINCIPLES TO GUIDE ENVIRONMENTAL HEALTH PRACTITIONERS IN
THEIR DAILY LIVES
Avoid obvious contradictions between your lilestyle and your professional role, such as owning big
and heavily polluting automobiles.
Keep your home as clean as feasible and avoid creating obvious pollution.
When pollution cannot be avoided, keep it to a minimuni, do it openly, and use the opportunity
as an object lesson to demonstrate that this must be changed.
Never try to conceal something in your lile that looks like a contradiction with your role as an en-
vironmental health professional; it will someday he used for embarrassment.
Participate visibly and personally in community efforts to improve the environment and do so out-
side of working hours to demonstrate personal commitment.
Concentrate on living a lifestyle that has less environmental imilpact than the lifestyle of those
arottnd you.
Do not try to be perfect or completely nonpolluting because this is impossible.
velop skills to do things and skills in working as a team member with other pro-
fessionals and the community.
The in-service learning process can be greatly facilitated by structured dis-
cussions and reviews of experiences in handling environmental health problems.
If a program for such discussions does not exist in your workplace, consider tak-
ing the initiative to get it started. The program could include regular reviews of
particularly interesting cases you and your colleagues have dealt with. It could
include all colleagues reading selected articles in scientific or professional jour-
nals or chapters in selected textbcoks, and discussing their content and the im-
plications for your work.
Formal higher-level training in environmental health topics is another way
to develop one's knowledge and skills,. The availability of such training varies
from country to country. National professional societies in the field usually main-
tain information about these types of courses. Courses promoted at the interna-
tional level can be found, for instance, in the inventories and databases provided
by the WHO.
The environmental health professional who wishes to be truly effective must
be committed to a lifelong effort of reading, thinking, and analysis to understand
the problems and the possible solutions. Above all, a capacity for sound judg-
ment is needed to know what will work in the real world, what will not work,
and how to achieve a workable solution in an imperfect world.
Professional Practice
Closely related to the role of environmental health professionals as technical ex-
pert is the skill that they show as practitioners. Professional practice as an envi-
ronmental health practitioner depends on the job and the setting but typically
requires mastery of a certain number of health indicators and standardized lab-
oratory tests (for example, to determine water quality) and an ability to inter-
pret the results and draw conclusions about the problem. These are basic skills
in technical proficiency, and environmental health professionals are expected to

be highly skillful and accurate in the performance of these duties. The profes-
sional must also have the necessary judgment for knowing what tests are needed,
when they should be implemented, and how the pieces of the puzzle fit into the
big picture in defining the problem. The environmental health professional must
then decide Ofl appropriate solutions and may have to convince others that one
approach is better than another or that any action is necessary at all. This means
that skills in communicating are just as important as technical skills.
An important aid to maintaining quality in professional practice is to support
and to work within associations and professional societies. These provide a fo-
rum for discussing new developments and for sharing educational materials. They
also create a network among professionals that tends to reinforce appropriate
standards of performance and expectations about appropriate practice.
Public Education and Capacity Buildinq

One of the most important functions of an environmental health professional is
to educate the public. It is most useful for environmental health professionals to
think in terms of creating opportunities for learning rather than to think of them-
selves as conduits of information. Because learning takes place in many ways, it
is useful for the environmental health professional to understand these different
modes of education.
The most effective educational encounters are usually those that take place on
a case-by-case basis, when an opportunity arises to explain something. Often this
occurs when the environmental health professional is consulted on a problem that
the learner wants to have resolved. In this situation, the learner is motivated and
receptive, and learns quickly and usually completely with respect to specific, con-
crete details. The learner may initially seem impatient with extraneous detail and
may not fully comprehend the context of the problem. The educator must resist
the temptation to be incomplete and must ensure that the learner does not leave
with a distorted idea of what the problem is about. In addition, this reductionist
approach to science has been blamed for the state of the environment, which re-
quires a more holistic approach to formulating and implementing feasible and sus-
tainable solutions. Thus, when providing the technical information to address a
specific problem, effort should be made to put the problem into an overall con-
text. How this is best done depends, of course, on the setting.
Teaching in school is perhaps the most familiar type of education. In this set-
ting, education is usually focused on teaching the background to a problem and
on understanding it thoroughly. The usual format is that of a teacher speaking
to a large group of people and the content is usually structured to explain the
problem from its beginnings or to outline how something works. The problem
with teaching working adults in this way, as noted above, is that adults are usu-
ally motivated by problems rather than by a desire to understand everything
there is to know about a topic. As adult learners tend to be results oriented, it is
generally most useful to provide frequent opportunities for them to ask ques-
tions, and one must make the presentation as concrete and practical as possible.
Often, teaching by exploring details of a case study is much more effective than
giving a lecture on the same topic.
In any case, some basic principles of effective teaching need to be appreciated

TARIF 124
COMPARISON OF EFFECTIVE TEACHING METHODS FOR ADULTS, CHILDREN,
AND YOUNG STUDENTS
Children and Young Students Adults
Teaching methods Lectures, seminars, games, Problem-solving exercises, special
and simulations projects
Teaching approach Systematic instructions, Start with learner's own interests
theory, history and problems, emphasize case
studies
How to handle Build Irom basics, provide Draw out basics Irom an exploration
fundamentals theory first of practical matters, introduce
theory as needed
Theory and practice Emphasize firm grasp of Emphasize practical appliiatious
theory that learner can that help learner to grasp theory
apply as needed
Setting Classrooms, regular sessions "Real-life" settings such as workplaces,
- community halls
by environmental health professionals in conducting this aspect of their tasks.

Educators generally believe that teaching working adults requires teaching meth-
ods that are different from those used for teaching children or full-time students.
Some expert educators note, however, that many of the methods developed for
teaching working adttlts also have a major role to play in traditional teaching set-
tings. Effective teaching methods that have been successfully applied in each of
these groups are shown in Table 12.4.
Community presentations are usually given in response to specific problems.
Residents of the community want the problem explained to them and want to
hear about how it affects them. They usually want to know what will be done
about the problem and can be very persistent in holding the authorities respon-
sible for solving the problem. Community residents may be less interested in de-
tailed explanations of the background to a problem and many not want to hear
elaborate discussions of the implications of the problem beyond the effect on
their own lives and their own community. There may also he individuals who
come to these tiieetings with a specific agenda of their own and will use this as
an opportunity to ask questions or make statements that are designed to change
community attitudes or to commit the authorities to a course of action that may
not he in the best interest of the community as a whole. The environmental
health professional needs to be prepared for this situation.
In making community presentations, it is very important for the environ-
mental health professional to maintain an appropriate attitude and demeanor.
Presentations in which professionals appear to be too proud, too distant, and too
busy to concern themselves with the residents own situations are doomed to fail-
ure and may cause great hostility in the crowd. Presentations in which profes-
sionals appear sympathetic, caring, accessible to the people, honest, and know!-
edgeable but not overbearing work best. Chapter 4 reviewed the key elements
in risk perception and risk communication. These should always be borne in mind
when preparing community presentations.

Education may also take place through the media. Environmental health pro-
fessionals must often speak to journalists. Journalists control what they write and
editors control how it appears, whether in newspapers or on television or radio.
Journalists take great pride in their writing and do not like to be manipulated in
their preparation of a story. As a result, it is very difficult for the environmental
health professional to control how a story will appear in the media and any ef-
fort to control the story will usually be resisted by the journalist who is inter-
viewing the professional. Efforts to distort or to downplay a story are very likely
to lead to vigorous efforts by the journalist to investigate further in the hope of
showing that there has been a cover-up. Most environmental stories are com-
plicated and require detailed explanations to understand the situation thoroughly.
Journalists usually do not have enough time to investigate routine stories prior
to their deadlines and they rarely have the specialized training in science needed
to understand the details. This places environmental health professionals at a big
disadvantage when they are interviewed. Usually the best approach is to be open
and honest, to keep the language about the problem simple, and to disclose freely
and quickly any reservations, unknowns, and difficulties one may face in deal-
ing with the problem. Otherwise, they are likely to come Out anyway and will
embarrass the environmental health professional and the agency that he or she
represents. Once a problem is admitted, however, it ceases to be as newsworthy.
It often helps to prepare a short and simple press release before meeting with
the media, so that the details can be kept straight. Sometimes, it helps to prac-
tice describing the problem in short, vivid sentences that can be quoted directly.
However, misquotes are inevitable. All practicing environmental health profes-
sionals have had some bad experiences with the media but there is no better way
to educate large numbers of people in the community. Tips for working with the
media were provided in Chapter 4. These should he reviewed before press con-
ferences.
A good approach to handling community education and media requests for
information is to create an information service or speakers corps within a pro-
fessional association. Community organizations and media can be informed that
if they would like to get an explanation of a particular problem or hear a speaker
on a particular topic, they can contact the organization and a qualified speaker
will be assigned.
Personal Example
Personal lifestyle was discussed in the section Ethical Principles That Guide Ac-
tion on Environmental Health, in the context of being ethically consistent. One
of the most powerful ways through which environmental health professionals
can influence other people is by setting a good example in their own lives. Liv-
ing in a way that is conserving of resources, nonpolluting (or at least minimally
polluting), respectful of others, and that does not involve conspicuous overcon-
sumption is one way to demonstrate to others that a lilestyle that is environ-
mentally responsible can also be satisfying.
Expectations on the part of the public place a heavy responsibility on envi-
ronmental health professionals. People are quick to see discrepancies between
what one says and what one does. On the other hand, it is difficult to be effec-

tive as a professional when one cannot use the same tools and systems as other
professionals, particularly in societies that arc wasteful of resources and that value
displays of wealth as symbols of power and authority. For example, bicycles are
effective and nonpolluting means of transportation at the local level, but it is dif-
ficult to be effective as a national authority on environmental health if one can-
not fly in airplanes or drive an automobile to get from one place to another.
Wearing second-hand clothes made from local materials may be a very respon-
sible and practical way to demonstrate concern at a local level, but this practice
is likely to be counterproductive when one is talking to a business person about
pollution-limiting measures or trying to persuade a national politician to change
a policy that has implications for the economy.
Another opportunity to demonstrate commitment to environmental quality
is to make one's own agency or workplace as environmentally sound as possi-
ble. Depending on the setting, this may mean encouraging recycling or reusing
materials in the office, arranging work schedules of employees to make it easier
to use less polluting public transportation, conserving energy in the building, and
trying to influence the ministry, agency, or institution of which one is a part to
reduce pollution, conserve energy, and recycle materials. For example, some hos-
pitals have formed green teams to review their procedures to reduce waste, im-
prove efficiency, and promote recycling and other environmentally sound mea-
sures.
Advocacy
A critically important role of environmental health professionals is to serve as
advocates for environmentally sound policies and practices, much akin to the
role of physician as the patient's advocate. This role overlaps the responsibilities
mentioned earlier for public education and implies attempting to influence deci-
sion makers to adopt enlightened policies.
Within the environmental health professional's role as a technical expert, it
is appropriate to advocate a preferred or scientifically rational solution to re-
solving a question after presenting an overview of the potential solutions and
their implications. It generally works best if the pro's and con's of each poten-
tial solution are spelled out and a justification is given as to why one option is
superior to the others. For narrowly technical problems, this is usually enough.
The analysis by the experts will decide the matter. However, most major deci-
sions are complicated by issues of cost, local history, public perception, political
acceptability, and interrelation with other problems in the community. For bet-
ter or for worse, it is up to the political decisk n-making bodies to decide on the
best course of action that takes all of these factors into account.
Although the decision as to how far to go in attempting to influence decision
makers is a personal isstie for each environmental health professional, it is part
of the professional's role to guide society in seeking the most appropriate solu-
tion. Depending on the country and political system, this may or may not be
easy to do. One approach is to form or join professional associations and soci-
eties and to work within them to develop recommendations and policies that will
influence decision makers. Often a statement on an issue prepared by a large or-
ganization carries much more weight than the opinion of an expert. It also shows

that the problem was discussed in detail and thought through. For issues that
are extremely urgent or serious, coalitions can be created among different orga-
nizations. These coalitions may issue statements, take positions, and express opin-
ions in the name of all the member organizations. Politicians usually take these
coalitions very seriously because they represent many different interests among
their memberships and show that there is a broad consensus supporting the p0-
sition. However, coalitions generally only work for specific issues and only then
for a limited time. They tend to be unstable over the long term because the in-
terests of each member organization will limit the degree of cooperation that can
be obtained.
Networking
A very effective way for environmental health professionals to enhance their role
and to increase their contribution to society is to network, by forming relation-
ships between themselves and their organizations. Networks can be formal or in-
formal, personal or institutionalized. They are created whenever colleagues keep
in touch and share ideas and resources. A professional in a network is in a much
stronger position than a prolessional in isolation.
Networks expand the range of options for dealing with a problem because
they enable professionals to get good ideas, share or loan needed resources, learn
about and adapt good ideas or inncvative methods, and continuously stay edu-
cated about developments in the field and in the region. Interdisciplinary net-
works can also be effective in keeping the various members aware of new de-
velopments in their fields of expertise. The simplest network is the set of
colleagues and friends in the field that environmental health professionals may
have and the organizations to which they belong. More sophisticated networks
may include WHO initiatives such as the Global Environmental Epidemiology
Network (GEENET) and the Global Environment and Health Libraries Network
(GELNET), which provide access to educational and practical tools by mail and
electronic mail.
Although national and international networks are very useful and important,
local or community networks may be exceptionally powerful when one needs
to solve a local environmental problem. It is very helpful to be able to draw on
community leaders, business representatives, scientists, and engineers as needed
to solve a particular problem, and because they know the community that they
live in, the solutions are likely to be more practical and feasible than solutions
proposed by colleagues who do not live there. There is also likely to be greater
support for proposed solutions.
Research and Documentation

A major responsibility of environmental health professicnals is to document prob-
lems in their communities and, where appropriate, to conduct research to un-
derstand them. This may mean original laboratory research for those specially
trained and with access to facilities, but more often it means a thorough inves-
tigation and consultation of references to determine how the problem started,
why it continues, and what alternatives there are for solving the problem.
Documentation may be invaluable by providing hard evidence that something

needs to be done and is often the key to motivating action. It also provides a
benchmark against which subsequent improvement or deterioration can be eval-
uated. Original research to investigate the nature of environmental problems is
difficult and often expensive. It requires special training and is often highly tech-
nical. However, most of our understanding of environmental issues has come
from this difficult process and from the commitment of dedicated investigators
who contributed facts, ideas, and analysis.
Although it is not always practical for an individual environmental health
professional to conduct research personally, it is always possible to support good
research. This can be done by encouraging talented students in the community
to follow careers in environmental science, raising funds for such work, provid-
ing investigators with access to data, talking about the need for research in the
community, and advocating support of research by government and professional
societies.
The roles of professional societies in supporting good research cannot be over-
stated. Not only do they often raise money for research themselves but they pro-
vide the networks for investigators to organize their studies, a forum for judging
the quality of research (sometimes just by providing an opportunity for it to be
discussed), and meetings at which research findings can he presented. They also
usually influence government and the private sector in supporting good-quality
research.
Study Questions
Assuming that you agree that professionals should get involved, in the issues
they study, what can you do with respect to each of the categories discussed in
the section Role of Environmental Health Profession? Be as concrete as possible,
with specific examples of actions that you might take.

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INDEX
Page numbers followed by b, f and t indicate boxes, figures and tables, respectively
Aboriginal peoples, vulnerability to polydispr'rsed. 182, 183

environmental hazards. 33-35, 331, respirable range, 184-85
34f shape, 185
Acceptable daily intake (API), 122-23, size, 182-85, 183f
144-45 thoracic fraction, 184
Acceptable level of risk )ALR), 128 ultrafine, 184
Acceptance of risk, factors affecting, 146-50, Aflatoxins, health effects, 252-53
148t-149t, 1501, 151h Africa, motor vehicle accidents, 305-6
Accidents See also Injuries Agenda 21, 7
industrial, 199-200, 200b, 362-63, 3621 Agent-host-environment triangle. 96-97
nuclear, 258-59, 325 Agricultural hazards, 273-80. 341
Acetic acid, health effects and sources, 19 it from fertilizers, 279
Acid, in hazardous waste, 339 infections. 273, 279-80
Acid Precipitation (acid rain), 220, 22 lb. injuries, 273
392-93 integrated pest management and, 278
control strategies, 393 with intensive farming methods, 279-80
fossil fuel consumption and, 322 from pesticides, 275-78, 277f
sulfate and, 194 prevention and control. 280
Acquired immunodeficiency syndrome Agriculture
(AIDS), spread of disease and, 60 alternative methods, 279
Action-based coping strategies, 147 energy needs, 314
Action on environmental health problems, global warming and, 382
399-409 occupational hazards. See Agricultural
ethical guidelines. 401, 402t. 4031 hazards
history, 11-14, 1 3h water withdrawal for, 217, 218f
minimal components, 400, 4001 AIDS, spread of disease and. 60
role of environmental health professionals, Air pollution, 14-15. See also specific pollutant
40 1-9 acidification of water from, 194, 220, 22 lb.
Administrative controls, 154 322. 392-93
Adsorption, 186 aerosol constituents, 182-86, 1831, 185f. See
Adult learners, teaching methods, 404-5, 405t also Aerosols
Advocacy, 407-8 anthropogenic, 181, 181
Aerosols, 182-86 community and, 20 1-7
aerodynamic diameter, 184 control, 204-6, 205h, 2061
annual levels, 298, 3001 gaseous constituents, 186-87
composition, 183-84, 1831 health elfects, 188-98, 1 89t, 191
course, 184 humidity and, 186
line, 184 mdoor
health effects, 1911, 195-96 from hioniass fuels, 291, 315-18, 31 5f
hygroscopic, 186 from Icssil fuels, 291, 318
inhalahle fraction, 184 from sick building syndrome, 291-92,
monodispersed, 182-83 2921
penetration and retention, 184-85, 1851 sources, 206-7, 291
421
Air pollution (continued) Animal dung, combustion, indoor air
industrial, 198-201, 1991 l)011Ution from, 315
from accidents, 199-200, 200h Animal studies
control strategies, 204 limitations, 123, 125
public exposure, 333-35 toxicity testing, 75-79
types, 198-99, 1991 Antibiotics, biological hazards. 59-60
in workplace, 200-201 Aral Sea, 218-19
inhalation, 187-88 Area sampling, 130
during inversion, 182 Arm vibration, 85
liquid constituents, 185-86 Aromatic hydrocarbons, 65
magnitude, 201-2, 2021 from food preparation, 266
microbiological, 207 health effects and sources, 191t
monitoring, 204-6, 205b, 206f Arsenic
from motor vehicles, 204, 2050, 3011) in drinking water, 215
overview, 1 80-88 in general environment and workplace, 347
particulate constituents, 182-86, 183f, 1851 Asbestos, carcinogenicity, 76h
See also Aerosols Ashestosis, 356b
photochemical, 199, 1 99t Ascorbic acid, deficiency, 248
point-source emissions, 199, 1991 Ash, 182
from power stations, 321-22 4speigillus humus, 252
precipitation and, 186 Asperqillus parasiticus, 252
reduction, 198, 199t, 333-34 Asphyxianms
sources, 201-2, 202t chemical, 188
urban, 201, 202, 202t, 298-300, 299f, 300f, simple, 188
3010, 331 Asphyxiation, 188
Air quality Assault, 100
exceedance, 203 Association, in epid emiological field
guidelines, 40, 401, 202-4, 203t investigations, 116
indicators, 163t Asthma
nondegradation policy, 203-4 air pollution effects, 189, 1901
Airborne exposure, 55t occupational, 357b
biological hazards, 57, 58 rates, as health indicator, 160
inhalation estimation, 132-33, 1 331 Aswan dam, schistosomiasis and, 323
personal monitoring, 130-31 Atom
Airshed, 202 characteristics, 84h
Alcohols, 66 unstable, half-life of, 84h
Aldehydes, health effects and sources. 191t Attrihutable traction, 114, ml 5b
Alexandria, Egypt, water pollution, 2220 Australia, bicycle use, 301h
Algal blooms, 220, 382, 3830
Alicyclic hydrocarbons, 63, 65 Bacteria
Aliphatic hydrocarbons, 63 fecal, water monitoring for, 222-23, 223t
Alkali, in hazardous waste, 339 growth, 60
All-terrain vehicles, 99-100 lifecycle, 5 5-56
Allergic alveolitis toxin production, 57, 250
extrinsic, 357h-358h Bacterial disease
in farmers, 280 loodhorne, 250-51, 2510, 266, 267f
Allergies, occupational, 36 1-62 global warming and, 383h
Alpha radiation, 84b temperature control, 266, 267f
Altitude, health effects, 90 waterborne, 225t
Alvcolitis, allergic Barometric pressure, health effects, 89-90
extrinsic, 357b-3 580 Barotrauma, 90
in farmers, 280 Basel convention, 394t
Amazon rain forest, deforestation, 388-90 Batteries, manufacturing hazards, 343
American Congress of Governmental Becquerel )Bq), 84h
Industrial Hygienists (ACGIH), 366 Behavior
Ammonia, 63 change, health education and, 156-58,
Analytical epidemiology, 107-8, 108f 158h, 158f, 159h
Analytical errors, exposure assessment, determinants, 157-58, 1 58h, 1 58f
136-37 Benefit-cost analysis
Anemia, iron-deficiency, 247 issues, 175
422 Index
UI pollution prevention in Japan, Brazil
1 74b-1 75h air pollution, 202, 202t
of radon nhitigation in Canada, 176-79, deforestation, 389-90
1781 British Smoke, 185
SCOPC of study, 175 Bromine, 62-63
steps, 172-73, 1731, 177-79 Bronchitis
valuation methods, 173, 175 air pollution effects, 189, 190t
Benzene industrial, 358h
in hazardous waste, 337 Brownian movement, 183
metabolism, 69, 70h Brucellosis, 279, 361
toxicity, 65, 349 Bubble concept, industrial air pollution, 204
Berms, 336 Building nsaterials, manufacturing hazards,
Beta radiation, 84h 343
Bhopat incident, 200, 200h Building-related illness, 29 1-92, 2921
Bias, epidemiological studies, 1091, 110 Bulk materials, environmental hazards,
Bicycle use 349-50
injuries, 98 Bunds, 336
promotion, 301h Burden of disease, 25-27, 26h. 271
Bioaccumulation, 335, 335f global, 27, 28t, 35-37, 36t, 37t
Bioactivation, 69, 701) household environment and, 36, 37t
Bioconcentration, 335, 3351 Burns, 92, 98-99
Biodegradation, 335 Byssirtosis, 342, 355
Biodiversity. 390-92
biological significance, 390-91 Cadmium
defined, 390 exposure
economic aspects, 391-92 in air, 401
loss, 392 dose-response relationship, 120, 1221
Biological exposure indices, 366 in food, 257
Biological hazards, 55-61 from industrial pollution, 346-47
defense mechanisms, 59-60 provisional tolerable weekly intake,
distribution, 59 257
exposure assessment, 131-32, 1 311 poisoning, 347
exposure routes, 55t, 58-59 Calcium, deficiency, 248
foodhorne, 58-59, 250-54 Calcium hydroxide, 63
growth, 60 Calcium oxide, 63
health effects. 60 Canada
investigation methods, 60-61 bicycle use, 301 h
microbiological standards, 224-25, 225t chemical hazard classification system, 80t
occupational, 361-62, 361h infant mortality rates, 33, 33f, 34f
spread, 57-58 water quality guidelines, 236
types, 55-57 Cancer. See also Carcinogen(s)
Biological oxygen demand of water. 341 from air pollution. 189-90
Biological warfare, 373 developmental models, 73-74, 128
Biologically effective dose, 129 environmental influences, 35
Biomagnification, 335, 335f from radiation, 86-87, 326-27
I3iomass fuels rates, as health indicator, 160
action priorities, 331 Carhamale cholinesterase-inhihiting
alternative fuel sources, 317-18 insecticides, 276h
direct effects, 316-17, 3161, 3171 Carbohydrates, requirements and sources,
indirect effects, 317 2441
indoor air pollution from, 291, 315-18, Carbon cycle, 3861
31 5f Carbon dioxide
upgrading, 318 atmospheric concentration, 384, 385
Bioprospecting, 391 global sinks for, 385, 388-90
Biotransformation, 69, 70b Carbon monoxide
Blooms, algal, 220, 382, 383h health effects., 1911, 196-97, 1 97t
Blue baby syndrome, 279 oxygen uptake inhibition, 188
Bogota, Colombia, water pollution, 222b Carbon tetrachloride, 66
Bovine spongilorrn encephalopathy )BSE), Carhoxyhemoglohin levels., 196-97, 196t,
253-54 197t
INDEX 423
Carcinogen(s) classification, 80, 80t
categories. 75, 75t information on, 79-80, 80t, 811
dose-response relationships, 127-28 organ-specific, 70-71, 720
groups, 75, 76h reproductive and developmental, 71, 73f
inorganic. 760 risk versus. 62
waterhorne, guideline values, 227 systemic, 70, 72h
in workplace, 360t testing, 75-79, 77t
Carcinogenesis in water, 215-16, 2161, 237
initiation, 73-74 acceptable daily intake, 22 5-26
multihit model, 128 guideline values, 226-27
multistage model, 73-74 Chemical warfare, 371, 373
progression, 74 Chernohyl nuclear accident, 259, 325
promotion, 74 Child abuse, 100
Cardiovascular effects C hildrcn
of air pollution, 188-89 injuries, 94-99, 98-99
of noise, 302 inortality rate, female literacy and, 31, 31
Case -control studies, I 09t, 110 vulnerability to environniental hazards,
design, llOf 27-29
nested, 113 China 10, bicycle use, 301h
toxic oil syndrome in Spain example, 111 h Chlamydiosis, 280
Case definition, 19 Chloracne, 337
Cataracts, ultraviolet radiation-induced, 88-89 Chlorinated cyclic hydrocarbons, in hazardous
Causation, tests of, 116, 1 16t waste, 337, 339
Causes of death, 23, 24t Chlorination
Central nervous system effects, of air by-products, 229h
pollution, 190 process, 229h, 230
Centro Hahana, Cuba, ecosystem analysis, Chlorine, 62-63, 349
2850 Chlorolluorocarhons (CFCs)
Chagas' disease, 290 atmospheric concentration, 384
Chemical Abstracts Service (CAS), 79 ozone depletion and, 377
Chemical asphyxiants, 188 Chloroform, 66
Chemical hazards, 61-80 Chloromethane, 66
absorption, 68, 68f Choking, 99
in air, overview, 180-88. See also Air Cholera
pollution loodhorne transmission, 291
carcinogenicity. 71-79, 76b svaterborne transmission, 210, 213,
classification, 62. 80, 80t 214b-215b, 2141
distribution. 68-69, 681 Chromic acid, 63
dose-response relationship, 122-23, 1251 Ch romosomal alterations, 74h
excretion, 68f, 69, 71f Cigarette smoking, indoor air pollution from,
exposure routes, 5 5t, 67-68 207
in food, 254-57, 255f Climate
monitoring, 255 ch ange. See Global warming
provisional tolerable weekly intake, 257 natural disasters, 395-96
sources, 254-55, 2551 Cluster studies, 116-17
genotoxicity, 71-75, 74b Coal
global, 397-98 as energy source, 318, 31 8t, 319, 31 9t,
health effects, 70-71, 720 3200, 321-22, 3211
in home, 350 extraction, pollution and hazards related to.
identification, 62, 118-19 340
from industrial pollution, 336-40 Coal workers pneomoconiosis, 3570
inorganic, 62-63 Cochlea, hair cells, 82
in manufacturing, 342-43 Codex Alimentarius Commission, 262, 263h
metabolism, 69, 70f, 71f Cold stress, 91
occupational exposure, 118-19, 355-98, Communicable disease. See Infectious disease
356b-358h Communicat ion
organic, 63, 65-67 with news media, 151 b
public exposure. 3 36-40 risk, 147-50, 1 50t, 1510
in recreational water, 237 Cornniunity. See also Human settlements
sensiovity to, 337, 338h-339b air pollution and, 201-7
toxicity, 61-62 chemical poisoning in, 350
424 Index
injury prevention, 95-96 Developing countries
networks, 408 industrial pollution, 13-14
presentations to, 405 malnutrition, 270t
rural. See Rural communities poverty, 43, 43t, 44
urban. See Urban areas sanitation, 2371, 239
Computer chips, manufacturing hazards, 343 water pollution, 220, 222h
Confidence interval, 114-15 water-related diseases, 211
Confounders, epidemiological studies, 1 09t, water supply, 2371, 239
110 Development
Conservation movement, 12 economic, environmental health and,
Consumer products, safety, 343 10-11
Consumption patterns, environmental health international, impact on water resources,
problems and, 44-45 219
Coping strategies, 146-47 sustainable, 7, 8, 14
Corrosive materials, 63 water pollution related to, 220, 221b
Cost-effectiveness analysis Developmental hazards, chemical, 71, 73f
issues, 175 Developmental toxicology, 27
of pollution prevention in Japan, Diagnosis of occupational or environmental
I 74h-1 75h disorders, 166
of radon mitigation in Canada, 176-79, Diagnostic tests, biological hazards, 60-61
I 78t Diarrheal disease
scope of study. 175 associated with water, 210, 212h
steps, 172-73, 1731, 177-79 from biological hazards, 57, 60
valuation methods, 173, 175 deaths from, 211
Creutzfeldt-Jakoh disease, 254 as health indicator, 160
Critical incident debriefing, 397 Dichlorodiphenyl-trichloroethane (DDT), 64f,
Crop rotation, 279 274, 275b, 398
Cross-sectional studies, 108, 1 09t Dichloromethane, 66
Cryptosporidiosis, waterborne transmission, Dietary preferences, disease and, 272-73
212h Diethyistilbestrol, structure, 641
Cuba Dioxin, in hazardous waste, 337, 339
bicycle use, 301b Direct casualties, 370
ecosystem analysis, 285b Disability-adjusted life years (DALY5), 25, 26h
Cumulative trauma disorder (CTD), 344, 361 global, 37, 38t
Cyanide, 188, 339.349-50 Disabled people, vulnerability to
environmental hazards, 32
Dams. See Hydroelectric power Disadvantaged groups, injuries, 95
Data preparation errors, exposure assessment Disasters, 394-97, 3951
137 drought as, 396-97
DDT (dichlorodiphenyl-trichloroethane), 64f, emergency actions, 394-95
274, 275b, 398 natural versus technological. 395-97,
Death, causes, 23, 24t 395t
Debt-for-equity swap, 390 psychological effects, 397
Decibel (dB), 82 Disease
Decompression eflects, 90 burden of, 2 5-27, 26h, 27f, 28t, 3 5-37, 361,
Deforestation, 387-90, 3891) 371
biomass fuel consumption and, 317 communicable. See Infectious disease
desertilication and, 387-88 demographic transition, 21-22, 22f
land degradation from, 272h dietary preferences and, 272-73
Demographic transition, 2 1-22, 221 environmental
Denmark diagnosis, 166
bicycle use, 3011) outbreaks, 362-63, 3621
healthy city program, 309 rehabilitation, 167
Desalination, 228 environmental influences, 35-37, 361-391
Descriptive epidemiology, 107, 108, 108f epidemiologic transition, 22, 231, 24-2 5,
Desertification, 272b, 387-88 24f
Deterministic effects global patterns, 2 1-35
dose-response relationship, 120-27, rate of, 113, 1131
121f-124f, 1271 vulnerable groups, 27-3 5
radiation, 86, 327 Disinfection of water, 230
Detoxification, 69 Displaced persons camps, 371, 372b
INDEX 425
Dose Electrical transformers, manufacturing
biologically effective, 129 hazards, 343
effective, 76 Electricity
infectious, 58-59 from alternative energy sources, 328-30,
internal, 129 328b, 329f, 329t
lethal, 76 versus biomass fuel consumption, 317-18
risk-specific, 128, 144-45 hazards, 324
total, 138 Electrolytes, requirements and sources, 244t
Dose-effect relationship, 119-20, 11 9f Electromagnetic fields, 87, 89
Dose-response relationship, 105, 119-28, Electromagnetic radiation, 87, 343
1 19f, 121t Electromagnetic spectrum, 87, 88f
for cadmium, 120, 122f Electronic products, manufacturing hazards,
chemical hazards, 122-23, 1251 343
high-risk groups, 127 Emission standards
for injuries, 121, 123f control at source by, 153
for lead, 120, 121f exceedance, 203
at lower levels, extrapolation, 125-27, 127f monitoring, 204
between noise level and annoyance, 121, 124f nondegradation policy, 203-4
for non-threshold effects, 127-28 for United States, 202, 202t
for physical hazards, 120, 122f Emotion-focused coping, 146
for threshold effects, 120-27, 121f-124f, Energy
1 27f hiomass fuel. See Biomass fuels
uncertainty factors, 123, 125-27, 125t, 127f consumption
Dose-response relationship, for ionizing cycle, 312
radiation, 86-87 trends, 312-15, 312f
DPSEEA framework fossil fuel. See Fossil fuels
for ecosystem health, 282, 283b-285b geothermal, 329, 329t
for environmental health indicators, 164, hydroelectric, 322-25, 329t
165h needs
for housing quality assessment, 286b-288h for agriculture, 314
relationship to PRECEDE-PROCEED model for basic human needs, 314
of health promotion, 158, 1 59h caloric requirements, 243
Draize test, 78 for health and sustainability, 3 11-12, 312t
Droplets, 185-86 for industrial production, 314-15
Drought, 396-97 for transportation, 314
Drownings, 98 in urban areas, 314
Dung, combustion, indoor air pollution from. nuclear. See Nuclear power
315 solar, 328, 328b, 3291
Dust SOU rces
defined, 182 action triorities, 330-31
deposition, 184-85, 185f alternative, 328-30, 328b, 329f, 329t
consumption by. 313-14, 313f
Ecological footprint, 44 risk comparison, 330
Ecological studies, 117-18, 1181 wind, 328b, 3291, 329t
Ecological vandalism, 375 Environment
Ecology movement, history, 12-I 3 defined, 5
Economic analyses of interventions, 172-79, deliberate destruction, 375
1731, 174b-175b, 1781 food security and, 271, 272h
Economic development, environmental health global degradation, 370
and, 10-11 global stability, 17-18
Ecosystem, defined, 3 human health and, 3-9
Ecosystem health, human health and, 3-4, human interaction with, health and, 6-8, 6f
17-18, 282-86, 283h-285b influences
Education on cancer, 35
health, 156-58, 1 58b, 1581, 1 59b on infectious disease, 35
public, 404-6, 405t on life expectancy, 2-3, 31
for women, 3 1-32 supportive, for health, 9, 9b
Effective dose at 50% (ED50), 76 Environmental disease
Elderly people diagnosis, 166
injuries, 95 outbreaks, 362-63, 362t
vulnerability to environmental hazards, 32 rehabilitation, 167
426 Index
Environmental epidemiology, 47-48, 402t. See Environmental justke, 300
also Epidemiology Environmental management
Environmental friendliness, of consumer hydroelectric dams, 324-2 5
products, 343 vector-borne disease, 324
Environmental health Environmental medicine, risk management
basic requirrments, 14-18 approach in, 164, 166-67, 168h
Consumption patterns and, 44-45 Environmental movement, history, 12-13
defined, 7 Environtuental noise, 300-304
demographic issues, 41-42, 42f Environmental Protection Agency (EPA), risk
economic development and, 10-11 communication rules, 1 Sot
emergency problems, 167, 169-72 Epidemiologic transition, 22, 231, 24-2 5, 24f
global concerns. See Global health concerns Epidemiology, 107-18
hazards. See Hazards analytical, 107-8, 108f
historical perspective, 10-14, 1 3h case-control studies, 1 09t, 110
impact, 5 design, 1 lOf
indicators. See also Environmental nested, 113
indicators; Health indicators toxic oil syndronie in Spain example, 1111)
guidelines for use, 21 causation, 116, 1 16t
macroeconomic policies and, 45 clttster studies, 116-17
monitormg, 18, 20-2 1, 20t, 130. See also cohort studies, 109t, 110-13
Exposure assessment design, 1 lOf
occupational health and, links between, historical, 113
38-41 prospective, 111, 113
poverty and, 43-44, 43t vinyl chloride and cancer example, I 12h
problents conlounding bias, 109t, 110
action on, 399-409 cross-sectional studies, 108, 109t
ethical guidelines, 401, 402t, 403t defined, 19
history, 11-14, 13b descriptive, 107, 108, 109t
mininial components, 400, 400t ecological studies, 117-18, 1 18f
role of environmental health environmental, 47-48, 402t
professionals, 401-9 ethical guidelines, 402t
emergency, 167, 169-72 historical, 108
of individuals, risk management interventional, 109t
approach, 164, 166-67, 168h limitations, 116
Envjronntental Healtit Criteria (IPCS), 62 molecular. 132
Environtnental health officer, 47 proportional morbidity studies, 113
Environmental health physician, 49-50 risk measures, 113-15, 11 3f, 11 Sb
Environmental health professionals statistical power, 116, 11 7t
advocacy, 407-8 steps, 19-20, 107-8, 108f
ethical guidelines, 401, 402t, 403t study designs, 108-1 3, 109t
networking, 408 Epoxides, formation, 70h
personal example, 401, 403t, 406-7 Epoxy compounds, 66
prolessional practice, 403-4 Ergonomic hazards, 97, 344, 360, 361
public education and capacity building, Ergonomist, 48
404-6, 405t Erosion, land degradation from, 272h
research and documentation, 408-9 Escherichia coli
roles, 46-50, 40 1-9 water grtidelines, 222-2 3, 223t
technical expertise, 401-3 water monitoring for, 61
training, 403 Estimated daily intake (EDT), via ingestion
transdisciplinary approach, 46-47 and skin absorption, 133-34, 13 Sb
Environmental health technician, 47 Estimation approach, time-activity
Environmental hypersensitivity disorder, 3 38h information, 132
Environmental inipact assessment (EfA), Estrogen, 64
139-42, 141b mimics, 64b-65b, 64f, 65-66
hydroelectric dams, 325 structure, 64f
public involvement, 142 Ethanol, 66
Environmental indicators Ethers, 66
and health indicators, linkage between, Ethical guidelines, environmental health
164, l65h professionals, 401, 402t, 403t
for health risk assessment, 21, 161, 1 63t- 1 64t Ethnic cleansing, 371
Environmental inspector, 47 Ethylene glycol, 66
INDEX 427
Europe Fishing, occupational hazards, 273
air quality guidelines, 202, 203t Fission, nuclear, 325
cheniical hazard classification system, 80t Flammable gases, 349
food standards, 262 Flocculation, 229-30
Event tree, 145 Fluoride
Excreta disposal systems, 231, 232, 232h deficiency, 248
Exposure in drinking water, 21 5-16, 230
airborne. See Airborne exposure Fluorine, 62-63
biological markers, 131-32, 13 It Food
foodborne. See Foodhorne exposure additives, 249-50, 261
human, defined, 128 and culture, 243, 245, 246h
public, to industrial pollution, 333-40, 335f flow scheme, 262-63, 264f
skin, 131, 134, 135b genetically engineered, 263-64
soilborne, 59, 133, 1 33t groups, 243, 245
total, 40, 128, 137-38 intake
waterborne. See Waterhorne exposure dietary standards and guidelines, 260
Exposure assessment, 18-19, 105-6, 128-37, inadequate, health effects, 16-17
129f irradiation, 264, 26 5-66
area sampling, 130 manufacturing hazards, 343
biological monitoring, 131-32. 13 it natural toxins, 249, 260-6 1
direct, 19, 130-32 new components, safety assessment, 261
environmental monitoring, 130 nutritional value, 260
errors, 136-37 poisoning, 249, 250, 2511)
indirect, 19, 132 preparation
personal monitoring, 130-31 in food services industry, 267-68, 268b
population sampling, 134-35, 1 36f in home, 266-67, 2671
quality assurance, 137 preservation, 265-66
sample size, 137 processing, 254-55, 264-65, 265t, 342
surveys, 132 production
time-activity information, 132 crucial conditions for, 269-70, 271f
Exposure control, 150, 157-58 occupational hazards. See Agricultural
along the path, 154, 1 55f hazards
framework for, 150, 152-53, 1 52f, 1 52t safety, 26 3-64
health education in, 156-58, 1 58h, 1 58f, I 59h trends., 16, 1 6f
at source, 153-54 world food situation, 268-69
at target/person level, 154-56, 1 56t, 1571 quality
Exposure routes. 54 assurance, 262-68, 264f, 265t, 268b
biological hazards, 55t, 58-59 criteria, 259-62
chemical hazards, 55t, 67-68 1)roperties, 259
physical hazards, 55t regulatory authorities and standard
Eye disease, occupational, 356 setting, 261-62, 263b
Eye irritation, from air pollution, 189, 1 90t safety, 261, 268b
standards, 260-62
Falls, 99 security
Famine, 396-97 environment and, 271, 272b
Farmer's lung, 280, 357h global trends, 271-73
Farming. See Agriculture storage, 254, 265-66
Fecal coliforms, recreational water guidelines, street-vended, 268h
236 Foodhorne disease, 248-59
Fecal-oral patliogens bacterial, 250-51, 2511), 266, 2671
foodhorne, 224-2 5 bovine spongiform encephalopathy as,
waterhorne, 224-25, 2251 2 5 3-54
Fecal pollution, indicator organisms, 222-23, fecal-oral pathogens, 224-25
223t fungal, 252-53
Fecal streptococci, recreational water parasitic, 251-52, 252b, 2531
guidelines, 236-37 prevention, 262-68, 2641, 2651, 268h
Fertility rates, 30t, 31 viral, 251
Fertilizers, 279 Foodborne exposure
Fetal development, critical periods, 731 biological hazards, 58-59, 249, 250-54
Fibers, 185 chemical hazards, 254-57, 255f
Fires, industrial, 349, 363 ingestion estimation, 133-34
428 Index
radioactive hazards, 257-59 Global Environment and Health Libraries
safety standards, 260-6 1 Network (GELNET), 408
Forest ecosystems Global Environment Monitoring System
hmmass fuel consumption and, 317 GEMS). 228h
changes, 272b, 387-88 air pollution program. 298, 2991, 3001
and global change, 388-90, 389h classification of chemicals in drinking
Forestry water. 215
occupational hazards, 273 food contamination program. 255
pollution and hazards related to, 341 Global Environmental Epidemiology Network
processing hazards, 341-42 )GEENET), 408
Formaldehyde Global Environmental Project, 18
in air, WHO guidelines, 40t Global Estintates for Health Situation Assessntents
health effects and sources, 191 and Projectio;ts, 354
Fossil fuels Global health concerns, 53, 368-98
atmospheric pollution from, 319 acid precipitation, 392-93
direct effects, 300b, 301f, 318t, 319-22, 319t hiodiversity, 390-92
extraction and processing hazards, 3181, chemical contamination, 397-98
319, 320h, 321, 321f climate change and greenhouse effect,
indirect clfects, 322 378-87, 379f-381f, 383b-385h, 3861
indoor air pollution from, 291, 318, 319 deforestation and desertification, 387-90,
pollution prevention strategies, 322 389b
use, 318 disasters, 394-97, 3951
Free erythrocyte protoporphyrin (FEP), 131 hazardous waste lransbouncfary movement,
Frostbite, 91 393-94, 394t
Fume fever, 3581) ozone depletion and UV radiation, 37 5-77,
Fumes, 183 376f, 378f
Fumigants, 274t warfare, 370-75, 370t, 372b
Fungal disease, foodhorne, 252-53 Global sinks, 385, 388-90
Fungicides, 2741 Global trends
Furniture, manufacturing hazards, 343 food security. 271-73
Fusion, nuclear, 326 water supply, 2 18-19
Global warming
Gaia Hypothesis, 4h biomass fuel consumption and, 317
Gannna radiation, 84h-85h cattses, 383-85
Gas(es) effects, 380-83, 381f
adsorption, 187 fossil fuel consumption and, 322
flammable, 349 greenhouse effect, 378-80, 379f, 383-85
natural malaria and, 382, 384h
as energy source, 318, 318t, 3 19-20, marine environment citanges associated
319t, 321-22 svith. 382, 383b
leaks, 321 solutions to problelTi, 385-87, 386t
solubility. 186-87 temperature changes associated with. 380,
sour, 321 380f
toxic tickhorne disease and, 382-83. 385h
health effects, 187 Glycols, 66, 348
inhalation, 357h Goitrogens, 246
Gene mutation, 74b Gray (Gy), 84h
Gene rearrangements, 74h Green labeling, 343
Genetic engineering, 263-64, 278 Green teams, 407
Geneva Protocol, 373 Greenhouse effect
Genotoxicity hiotnass fuel consumption and, 317
chemical hazards, 7 1-75, 741) description, 378-80, 3791
types, 74h fossil fuel consumption and, 322
Geological activity, natural disasters, 396 global warming and, 378-87, 379f-381f,
Geothermal energy, 329. 329t 383b-385h, 386f
Giardiasis Guerrilla warfare, 374
foodhorne transmission, 2 52b, 25 3f
waterborne transmission, 21 2b 1-laddon's injury reduction strategies, 101, 101
Global burden of disease, 27, 281, 3 5-37, 36t, Halogenated hydrocarbons, 66, 67b
37t Halogens, 62-63
Global ecological changes. 369 Hand vibration, 85
INDEX 429
Hazard Analysis and Critical Control Point Health hazard transition, 25
)HACCP) system, 265, 2651 Health indicators, 21, 21 t, 160, 161, 1 65t
Hazard audits, 118 and envirotimetital indical ors, linkage
Hazardous wastes between, 164, 165h
disposal, 339-40 Heallh physicist. 48
incidents involving, 337 Health policy analyst, 48
public exposure, 336-40 Health promotion
storage, 336 conceptttal models, 158, 1 59h
transboundary movement, 393-94, 394t defined, 9
Hazards, 52-103 responsibility for, 6
biological, 55-61. See also Biological hazards "Healthy Cities" program, 306-10, 307b
chemical, 61-80. See also Chemical hazards actions taken, 309-10
classification, 54 characteristics, 307-8
defined. 53 regional influence, 308-9
ergonomic, 97, 344, 360, 361 Hearing
global, 53, 368-98. See also Global health conservation programs, 83, 85
concerns loss
hierarchy of controls, 150, 152-53, 1521, 1 521 noise-induced, 83
identification, 105 incidence, 355
epidemiologic investigations, 107-18 surveillance programs, 167, 1 68h
field investigations, 118-19 sound intensity and, 83
measurement of health effects, 19-20 Heal loss, mechanisms, 91
mechatsical, 92-1 02. See also Injuries Heat stress, 91-92
physical. 80-92. See also Physical hazards Heat stroke, 91-92
psychosocial, 102-3, 344, 350, 362 Helmet use, 98
routes of exposure, 54, 551 Helnunth, 59, 225t
traditional versus modern, 2, 24-25, 541 Hepatitis A virus, foodhorne transmission, 251
types, 25, 53-54 Herbicides, 274t
vulnerability to, 27-35 Historical descriptive smtidies, 108
in children, 27-29 HIV (hutnan immunodeficiency virus), spread
in disabled people, 32 of disease and, 60
in elderly people, 32 Home
in indigenous peoples, 3 3-35. 331' 341 chemical poisoning in, 350
in women, 29-32 environment, burden of disease and, 36,
Headache, from air pollution, 190t 371
Health (human). See also Environmental health; lood preparation in, 266-67, 267f
Occupational health and safely injuries, 98-99, 290
defined, 4 Host-agent-environment triangle. 96-97
ecosystem health and, 3-4, 17-18, 282-86, Housing. See also Human seltlements
283b-285h communicable diseases and, 289-90
energy needs for, 311-12, 3121 health and, 286h-288h, 288-92, 2881
environmental influences, 35-37, 36t-39t physical hazards, 290-92
housing and, 286h-288h, 288-92, 288t psychosocial problems and, 292, 2921
human adaptability and, 8-9 toxic exposures, 29 1-92, 292t
human interaction with environment and, Human health See Health (human)
6-8, 61 Human imniunodeficiency virus (HIV), spread
nutrition and, 243-48. See also Nutrient(s) of disease and, 60
poor. See Disease among hospital workers, 361
poverty and, 43-44, 43t Human settlements, 281-310. See also
supportive environments for, 9, 9b Community
urbanization and, 297-306. See also basic health reqrtirenlents, 17, 282, 285-86
Urbanization as ecosystems, 282, 283h-285b
vitamins and, 2471) housing qualily assessment, 286h-288h
Health and Geographic Infortnation System Humidity, air pollution and, 186
(HEGIS), environmental indicators Hunting, occupational hazards, 273
in, 161, 163t-164t Hydrocarbons, 63
Health and safety consnsittee, 352 alicychic, 63. 65
Health education, as risk managemenl tool, aliphatic, 63
156-58, 158b, 158f, 159h aromatic, 65
Health effect, defined, 19 frons food preparation, 266
Health hazard evaluations, 118 health effects and sources, 1911
430 Index
chlorinated cyclic, in hazardous waste, 337 noise-related, 83-84
339 processing industries, 341-42
halogenated, 66, 67h public exposure, 333-40, 335f
polychiorinated, 66, 67h service industries, 343-44
Hydroelectric power, 322-25 solvents, 347-49
electricity hazards, 324 water
environmental management, 324-25 control. 2 34-35
health effects, 323-24, 3291 public expostire, 335, 3351
use, 322-23 tndustrial production, energy needs, 3 14-15
Hydrofluoric acid, in hazardous waste, 339 Infections, 561
Hydrogen cyanide, 188, 339, 349-50 housing and, 288-89
Hygiene, infections and, 288-89 respiratory
Hypersensitivity pneumoriitis, 3 57h- 3 58h from air pollution, 189, 1 90t
Hypothermia, 91 from biological hazards, 60
from indoor air pollution, 207
Illness. Set' Disease toxic reaction versus, 57
Immune defenses water-dispersed, 213
abnormalities, ultraviolet radiation-induced, Infectious disease
89 from agricultural hazards, 273, 279-80
biological hazards, 59-60 from biological hazards, 60
lot inunization, control at target/person level deaths from, 56t
by, 155-56 environmental influences, 35, 57-58
Inimunotoxicity, chemical hazards, 72h toodborne, 249, 250-51
Impairment assessment, 167 bacteria causing. 250, 251h
Incidence of disease, 19, 113, 11 3f parasitic, 251-52, 252b, 253f
Income, dietary preference and, 272-73 historical concern with, It
Indigenous peoples, vulnerability to housing and, 289-90, 2891
environmental hazards, 33-35, 33f, 34f immunization against. 155-56
Indoor air pollution occupational, 361, 361 b
front hiornass luels, 291, 315-18, 31 5f spread, 56-57, 38
from fossil fuels, 291, 318 water-associated, 210-13, 212h
from sick htulding syndrome, 291-92, 2921 Inlectious dose, 58-59
sources, 206-7, 291 Ingestion estimation, 133-34, 1 33t, I 35h
Industrial accidents, 199-200, 200b, 362-6 3, tnhalable traction, 184
362t Inhalation of toxicanls, 187-88, 357h
Industrial controls, hierarchy of, 150, 152-53, exposure esti nation, 132-33, 13 3t
152f, 1521 oxygen deprivation from, 187-88
Industrial cleveIoptnent, environmental health smoke-related, 316, 317t
and, 10-11 inhalation studies, toxicity testing, 78
Industrial lires, 349, 363 Injuries, 92-102
Industrial pollution agriculture-related, 273
air, 198-201, 199t in children, 94-95, 98-99
from accidents, 199-200, 200b cost, 94
control strategies, 204 cultural attitudes toward, 93
pit blic exposure, 333-35 in disadvantaged groups, 95
types, 198-99, 199t dose-response relationship, 121, 1 23f
in workplace, 200-20 1 in elderly persons, 95
arsenic exposure, 347 home-related, 98-99, 290
hulk rosy materials, 349-50 impact, 93-94
cadmium exposure. 346-47 intentional. 100
chemical contamination, 336-40 motor vehicle, 97-98, 101, 101t, 121, 123f,
in developing countries, 13-14 305-6
extent. 333, 334h occupational, 95, 96-97, 360-61
hazardous waste, 3 36-40 prevention
historical concern with, 12-13, 14 active versus passive, 100-101
by industry, 340-44. See also Occupational community, 95-96
hazards Haddon countermeasure strategies, 101,
lead exposure, 344-45 1 0 It
manufacturing, 342-43 phases, 101. IOU
materials extraction, 340-41 workplace, 95, 96-97
mercury exposure, 345-46 recreation-related, 98-100
INDEX 431
Injuries (continued) Kidney toxicity, chemical hazards, 721)
repetitive strain, 344, 361 Kuru, 254
settings, 95-96
SOClOCCOflOfliic factors, 93 Laboratory analytical scientist, 48-49
surveillance systems, 93-94 Lagoons, aerated, 235
traffic-related, 97-98 Land
Insect vectors, global warming and, 382, 384h degradation, environmental stresses leading
Insecticides, 274t, 276h to, 271, 272h
Internal dose, 129 development and ownership, rural
international Agency for Research on Cancer communities, 296
(IARC), 24, 75, 75t environmental health hazards, 54, 5 5t
International Chemical Safety Card, 80, 811 Land mines, 374
International development, impact on water Laser light, health effects, 89
resources, 219 Latin America, cholera epidemic, 213.
International Drinking Water Supply and 214h-2151), 214f
Sanitation Decade, 237, 239-40 Lead
International Monetary Fund (IMF), 45 exposure
International networks, 408 in air, WHO guidelines, 40t, 198
International Program on Chemical Salety dose—response relationship, 120, 121
(IPCS) in food, 256-57
food standards, 261-62 health effects, 1911, 198
personal protective equipment guidelines, industrial pollution, 344-45
155 learning disabilities from. 190
publications, 62 provisional tolerable weekly intake, 257
reference materials on environmental poisoning. 345
hazards. 170, 1 70h incidence, 355
International Register of Potentially Toxic surveillance system, 160-61. 1621)
Chemicals (IRPTC), 61-62 Leptospirosis, 273, 279, 361
Interventional epidemiology, 1091 Lethal concenlration at 50% (LCSO), 76
Interventions, economic analyses, 172-79, Lethal dose at 50% (LD50), 76
1731, 174b-175h, 178t Leukemia, from radiation, 326
mutt diet, 246h Liige, healthy city program, 309
Inversion, air pollution during. 182 Life expectancy. 23
Iodine, 62-63 environmental influences, 2-3, 3f
deficiency, 246 Lifetime individual risk, 138
in drinking water. 216 Light, laser, health effects. 89
tod ne - 1 3 1, afte r nuclear reactor mat in oct ion, Lighting, poor. 89
2 58-59 linkage Methods for Environmental Health
Ionizing radiation Analysis, 21
carcinogenicity, 76h Lipids, requirements and sources, 2441
defined, 85 Liver toxicity, chemical hazards, 72h
dose—response relationship. 86-87 Liverpool, healthy City program, 309
health effects, 8 5-87 Logging wastes, combustion, indoor air
nonthreshold effects, 86 poll ciii (in from, 3 1 5
sources, 86 London Fog, 193, I93b, 194f
threshold effects, 86 Lower Seyhan Irrigation Project,
Iron environmental impact assessment.
deficiency. 247-48 141 h
exposure, health effects, 198 Lowest observed adverse effect level (LOAEL),
processing hazards, 341 121-22, 124f
Irrigation, waslewaler for, 235-36 Lung .3'i' also R espiratory
Isocyanates, asthma from, 357h black, 357h
Itai-itai disease, 347 cancer, from uranium nsining, 326
disease
Japan in larmers, 280
mercury poisoning in. 258h, 346 occupational, 355, 356b-3581)
pollution in, economic analysis, 1 74b—I 75h from smoke inhalation, 316, 3171
Joint health and salety committee. 352 dust particles in, 184-85, 1851
larmer's, 280. 357b
Karachi, Pakistan, water pollution in, 222h white, 356h
Karasek model, 102 Lynle disease, 382
432 Index
Macroeconomic policies, environmental Microorganisms, health effects and sources, 191
health problems and, 45 Milan, Italy, healthy city program, 309
Mad-cow disease. 253-54 Mivamata, Japan, mercury poisoning, 25$b,
Malaria 346
and climate change. 384 Mineral fibers, synthetic, carcinogenicity, 761)
Maillard reaction, 266 Minerals
Malnutrition mining hazards, 340
health effects, 245-48, 269b requirements and sources, 245t
world situatiOn, 268-69, 269h, 270t Minimal infectious dose, 58-59
Manganese exposure, in air, WHO guidelines, Mining industry, pollution and hazards
401 related to, 340
Manufacturing, pollution and hazards related Mist, 186
to, 342-43 Molecular epidemiology, 132
Mar del Plata Action Plan, 237 Molluscicides, 2741
Marine environment, global warming and, Monocu Iture, 391
382, 383h Montreal Protocol, 377
Marker of effect, 131-32, 1 311 Mortality rate
Material Safety Data Sheet (MSDS), 169 for children, female literacy and, 31, 311
Ma lena Is infant, 33, 331, 341
building, manufacturing hazards, 343 injury-related, 93
bulk, environmental hazards, 349-50 trends, 23-25, 243
exnaction, industrial pollution fron, 34011 Mortality ratio, standardized, 114
Maximum allowable concentrations, 365 Mosqu i los
Mechanical hazards, 92-102. Sec also Injuries anophelene and colicine, 382
Media Motor vehicles
Communication guidelines, 151 h air pollution control strategies, 204, 205b,
education through, 406 301 h
Medical waste hazards, 343 injuries, 97-98, 305-6
Megacities, 293, 294t dose-response relationship, 121, 1231
air pollution, 201, 202, 2021 Haddon matrix analysis, 101, 10 It
Megamouse toxicity studies, 78 off-road, 99-100
Melanoma usage, 304-5, 305f
malignant, 377 Mucosal irritation, from air polltttion, 189
non-malignant, 377 Multidisciplinary team, 46-47
Meningitis, housing conditions and, 290 Multiple chemical sensitivity, 337, 3381)-339h
Mercury Mutation fixation, 73-74
exposure Mvula Trust, South America, 238h-239b, 240
in air, WHO guidelines, 40t Mycotoxins, 252-53
in food, 257, 258h
health effects, 198 National Institute for Occupational Safety and
industrial pollu I ion, 345-46 Health (NIOSH), 79
provisional tolerable weekly intake, 257 Natural disasters, 395-96, 3951, 397
poisoning, 258b, 346 Natural gas
Metals. See also .sj'eo fic iiietal as energy source, 318, 3181, 31 9-20, 31 9t,
fume fever, 358b 321-22
in hazardous waste, 337 leaks, 321
mining hazards, 340 Natural resource conservation, historical
processing hazards, 341 movement, 12
tOxic, 63, 344-47 Nephelometric turbidity units, 237
trace, health effects, 191 t, 198 Netherlands, bicycle usc', 301b
Metastases, 74 Networking, 408
Methane, atmospheric concentration, 384, Nectrotoxicity, chemical hazards, 721)
385 Neutron radiation, 85b
Methanol, 66 News media
Met hylne rcu ry contmtmnication gctidelines, 151 h
in food, 257 education through, 406
health effects, 546 Nile Waters Agreement, 219
Microbiological air pollution, in door, 207 Nitrates
Microbiological standards, biological hazards, in drinking water, 216
274-25, 225t health effects, 279
Microclectronks, manuiarturing hazards, 343 in selected river systetils, 216, 2161
INDEX 433
Nitric acid, in hazardous waste, 339 agricultural sector. See Agricultural hazards
Nilrogcn dioxide airborne, 200-201
in air, WHO guidelines, 40t biological, 361-62, 36 lb
health effects, 194-95, 195t carcinogenic, 360t
Nitrogen-fixing plants, 279 chemical, 118-19, 355-58, 3561)-358h
Nitrogen oxide dimensions of health problems, 354-55
atmospheric concentration, 384 distribution, 355
corrosive effects. 63 environmental health hazards and, links
health effects, 191t, 194-95, 1951 between, 38-39
No observed adverse effect level (NOAEL), ergonomic, 97, 344, 360, 361
121, 124! exposure standards, 364, 365-66
No observed effect level (NOEL), 122 fossil fuel extraction and processing. 3 18t,
Noise 319, 320h, 321, 321f
annoyance with, 121, 124f, 302-3, 303h identification, 118-19
cardiovascular effects, 302 manufacturing, 342-43
control, 83, 303-4 materials extraction, 340-41
defined, 82 mechanical, 360-61
direct effect, 301 monitoring, 364-65. 365t
environmental (community), 300-304 physical, 358-59
guidelines and standards, 302, 303, 3041 prevention approaches, 363-66
health effects, 83 processing industries. 341-42
hearing loss from, 83 protective equipment, 364
incidence, 355 psychosocial, 102, 350, 362
surveillance program, 167, 168h service industries, 343-44
indirect effects, 301 types, 3 54-62
industrial, control, 83-84 uranium mining. 326
level, of familiar sounds, 83t worker training and, 364
pollution, service industries. 343-44 Occupational health and safety
sleep disturbance from. 302 air quality guidelines, 40, 40t
sound intensity measurement. 82-83 environmental health and, links between.
Nuclear accidents. 2 58-59, 325 38-41
Nuclear fission, 325 internal responsibility for, 351-52
Nuclear fusion, 326 prevention framework, 363-65
Nuclear power, 32 5-28 for small enterprises, 351
deterministic effects, 327 social context, 3 50-54
fusion-based, 326 surveillance programs. 364-65. 365t
safety approaches. 327 UI mvontcn, 352-54
stochastic effects, 326-27 ivorkers' compensation and, 352
use, 32 5-26 Occtipational health and safety inspector.
waste disposal, 327-28 50
Nuclear reactor malfunction, 2 58-59 Occupational health nurse, 49
Nuclear warfare, 373-74 Occupational hygienist, 49
Nuclear weapons plants, contamination, 373-74 Occupational injury, 360-61
Nuclear winter, 373 ergonomics and, 97
Nutrient(s) prcvetltion, 95. 96-97
deficiencies, 24 5-48 Occupational overuse syndronie, 344. 361
world situation, 268-69, 2691), 270t Ocean currents, global warming and, 38 1-82
recommended intake, 260 Odds ratio, t I 3f, 114
requirements, 213, 244t-245t Odor pollution, processing industries, 341,
342
Obesity, health effects, 243 Oft-road vehicles, 99-100
Observational approach, time -activity Oil
information. 132 as energy source .318, 31 8t, 319, 31 9t,
Occupational and environmental health 321-22
physician, 49-50 extraction, pollution and hazards related to,
Occupational and environmental medicine, 340
risk management approach in, 164, Olefins, 63
166-67, l68h Operatimig practices, control at source by,
Occupational exposure levels (OELs). 365 153-54
Occupational hazards. See also Industrial Organic polltitamits, persistent, 67b
pollution Organic solvents, 66-67
434 Index
Organization for Economic Cooperation and Photochemical air pollution. 199, 1991
Development (OECD) countries Physical hazards. 80-92. See also specific type
anthropogenic air pollution in, 181, 181f dose-response relationship, 120, 122f
energy consumption in, 312 housing-related, 290-92
Organophospliates, 276h, 339 occupational, 358-59
Our Common Future (WCED), 7 recreational water, 237
Our Planet, Our Health (WHO), 6, 239-40 routes of exposure, 551
Outbreaks, environmental disease, 362-63. types, 80. 82
362t Plant fibers, processing hazards, 342
Overcrowding, communicable disease and, Playground equipment, 99
289-90 Pneumoconiosis, 185, 356h-357b
Oxygen uptake, inhibition, 188 Pneumonitis, hypersensitivity, 357h-3581)
Ozone Poisonirtg
atmospheric concentration, 384 cadmium, 347
corrosive effects, 63 chemical, in home, 350
depletion food, 249, 250. 251h
health effects, 377, 378f inadvertent, 99
stratospheric, 375-77 lead. See Lead, poisoning
tropospheric accumulation, 375 mercury, 258h, 346
and UV radiation, 375-77, 3761, 378f Political violence, too
health effects, 190, 19 It, 192, 192f, 196 Polluter-pays principle, 240
Polybrominated biphenyls (PB Es), in food, 256
Painter's syndrome, 348 Polychlorinated hiphenyls (PCB5)
Paper industry, hazards. 341-42 average daily intake, 256f
Para-dichlorohenzene, acceptable daily intake, bioaccumulation and hiomagnification, 335,
1261) 335f
Parasitic disease in food, 254, 255-56, 256f
foodborne, 251-52, 2 52h, 253f in hazardous waste, 337, 339
tropical, 57 Polychlorinated hydrocarbons, 66. 671)
Parental leave, 354 Polycyclic aromatic hydrocarbons
Particles from food preparation. 266
in air. Ses' Aerosols health effects and sources, 191
dust, deposition, 184-85, 185f Polycyclic henzene rings., 65
PCBs. See Polychlorinated hiphenyls (PCB5) Polymer fume fever, 358h
Pentachlorophenol, in hazardous waste, 337, Polyphenyl, 65
339 Poor health .9cc Disease
Peripheral neuropathy, from solvents, 348 Population at risk, definitions, 19-20
Persistent organic pollutants, 67h, 398 Population displacement, hydroelcctric dams
Personal tisonitoring, exposure assessment, and, 323
130-31 Population growth, environmental health
Personal protective equipment (PPE) problems and, 41-42, 421
control at target/person level by. 154-55, Population sampling, 134-35. 1361
1571 Post-traumatic stress syndrome, disaster-
for farmeim, 280 related, 397
guidelines, 155 Potassium hydrcxide, 63
against occupational hazards, 364 Potential years of life lost (PYLL)
program checklist, 1561 injury-related. 94
Personality, stress response and, 147 stticide -related, 100
Pest management, integrated, 278 Poverty
Pesticides environnsental health problems and, 43-44,
categories. 274t 43t
defined, 274 urban areas, 297, 2981
exposure, populations at risk, 275-77. 277f Posve r
in hazardous waste, 339 energy. See Energy
production and use, 274-75, 275h, 276h statistical, 116, 1171
toxic effects, 277-78, 2781 Power stations, air pollution from, 321 -22
Petrochemical industries, processing PRECEDE-PROCEED model of health
hazards, 341 promotion, 158, 1 59b
Petroleum gas, liquid, versus hiomass fuel Precipitation
consumption, 317-18 air pollution and, 186
Phenols, health effects and sources, 191 global warming and, 38 1-82
INDEX 435
Pregnancy leave, 354 nonstochastjc effects, 86, 327
Press conferences, 406 stochastic effects, 86, 326-27
Pressure, health effects, 89-90 ultraviolet See Ultraviolet radiation (UVR)
Prevalence of disease, 19, 113, 1131 Radioactive contaminants, food, 257-59
Prion, 55, 254 Radioactivity u iii 1, 84h
Prion disease, 253-54 Radionuclides, internal emitters, 258
Problem-focused coping, 146-47 Radon, 87
Process standards, control at source by, 153 health effets and sources, 1911
Processing industries, pollution and hazi rds mitigation, economic analysis, 176-79, 1781
related to, 341-42 Random sampling, stratified, 135
Product standards, control at source by. 153 Rate of disease, 113, 1131
Professional associations, 407-8, 409 Recommended dietary allowances, 260
Professional practice in environmental health, Recreational injuries, 98-100
403-4. See also Environmental health Recreational water, physical and chemical
professionals characteristics, 237
Promoter, 74 Relorestation, 388, 390
Propanol, 66 Refugee camps, 371, 372h
Proportional morbidity studies. 113 Refugees, 371
Protective equipment Registry of Toxic Effects of Chemical
control at target/person level by, 154-55, 157f Substances (RTEC), 79
for farmers, 280 Rehabilitation of occupational or
guidelines, 155 environmental disorders, 167
against occupational hazards, 364 Repetilive strain injuries, 344, 361
program checklist, 1 56t Representative errors, exposure assessment, 136
Proteins, requirements and sources, 244t Reproductive hazards. occupational, 354, 359t
Protozoa Research, by environmental health
lifecycle, 55-56 professionals, 408-9
waterborne, 225t Respiratory effects
Psychological effects, disasters, 397 of air pollution, 188-89
Psychosocial hazards, 102-3 of ozone, 192, 1 92f
occupational, 102, 350, 362 Respiratory infections
service industries, 344 from dir pollution. 189, 190t
tirban areas, 102-3 from biological hazards, 60
Psychosocial problems, housing and, 292, 292t from indoor air pollution, 207
Public education, 404-6, 4051 Risk
Public exposure, to industrial pollution, acreptable level of, 128
333-40, 3351 acceptance, 146-50, I 48t- t49t, 1 501, 1511)
Public Health Act, 11 assessment, 104-2 See also Risk assessment
Public health inspector, 47 characterization, 106, 1 57-39, 1 38t
Public health laws, 1] communication, 147-50, 1 501, 1 Sib
Pulp and paper industry, processing hazards, comparison, for energy sources, 330
341-42 defined, 53
diniensions, 1 48t- 1491
Quality-adjusted life years (QALYs), 25 evaluation, 144-46
Quality assurance with no historical data, 145-46
exposure assessment, 137 versus standards or guidelines, 144-45
food, 262-68, 264f, 265t, 268h incremental, 114, 11 Sb
lifetime individual, 138
Radiation management, 143-79. 5cc' also Risk
alpha, 84h ma nageni cut
basics of, 84h-85b measures, 113-15, 1131, 115h
beta, 84h ilionitoring, 160-64
cancer from, 86-87, 326-27 health surveillance systems, 160-61,
electromagnetic, 87, 343 161h, 1621)
gamma, 84h-85h indicators in, 161, 1631-165t, 164, 1 65h
hazards, 85-89 perception, 146-50, 148t- 149t, 1 50t, 151 b
ionizing, 76h, 85-87 pol)tilatfoii at, 19-20
leukemia from, 326 toxicity versus, 62
neutron, 85b Risk assessment, 104-42
non ionizing, 87-89 dose-response assessment, 105, 119-28, 1211
436 Index
environmental impact assessment and, Sanitation, 231-33
1 39-42 Costs, 233, 234t
exposure assessment, 105-6, 128-37, 1291 in developing countries, 2371, 239
in field situations, 139 excreta disposal systems, 231, 232, 232h
generic versus specific, 106 poptilation coverage, urban areas, 231, 233,
hazard identification, 105, 107-19 233t
health, environmental indicators for, 21 Sao Paulo. Brazil, air pollution, 202, 202t
161, 163t-1641 Saturated aliphatic hydrocarbons, 63
for nonthreshold effects, 127-28 Sawdust, combustion, indoor air pollution
qualitative, 106-7 from, 315
risk characterization, 106, 137-39, 1381 Schistosomiasis
sources of uncertainty, 106, 1071 Aswan dam and, 323
steps, 105-6, 106f waterborne transmission, 210, 21 2b, 382
for threshold effects, 120-27, 1211-1241, Scorched-earth strategies. 371
1271 Screening tests, for surveillance programs,
Risk difference, 114, 11 5h 160, 161h
Risk management, 143-79 Sea level, global warming and. 382
approach, 144, 144f Seattle, Washington
to environmental health concerns of bicycle use, 301 h
individuals, 164, 166-67, 168b healthy city program, 309
to environmental health emergency, 167, Sensitivity analysis, 106
16 9-7 2 Service industries
communication of risk, 147-50, 150t, 15 lb pollution and hazards related to, 343-44
control of exposure, 150, 152-58 psychosocial hazards, 344
along the path, 154. 1551 Sexual abuse, 100
framework for, 150, 152-5 , 1521, 1 52t Shanghai, China, water pollution, 222b
at source, 153-54 Shanty-towns, 286
at target/person level, 1 54-56. 1 561, 1 571 Shellfish poisoning. 382
delined, 105 Shigellosis, foodhorne transmission, 251
evaluation of risk, 144-46 Short-term exposure levels, 366
health education in, 156-58, 1 58b, t 581, 1 59b Sick building syndronie, 29 1-92, 292t
monitoring of risk, 160-64, 161 b, 1621), Sievert (5v), 84h, 86
163t-165t, 165b Silent Sprinq (Carson), 12
perception and acceptance of risk, 146-50, Silicosis, 356b-357h
148t-149t, 1501, 1511) incidence, 355
Risk ratio, 113-14, 1131 from uranium nlinirlg, 326
Risk-specific dose (RsD), 128, 144-45 Silo eniptier's disease, 280
Rodenticides, 2741 Silo filler's disease, 280
Rtimor control, 171 Skin
Rural comni.unities absorption, factors affecting, 134
economy, 295-96 cancer
environmental protection implications, 297 ozone depletion and, 377, 3781
land development and ownership, 296 ultraviolet radiation-induced, 76b, 88
time and space differences, 295 chemical hazards, 72h
values, 296 disease, occupational, 355, 356
cxpos tire
Safe Community Network, 96 estimation, 134, 1 35b
Safety factors, dose-response relationship personal monitoring, 131
123, 125-27, 125t, 1271 Sludge, activated, 235
Salety prolessional, 50 Sludge blanket reactors, upilow anaerobic,
Salmonellae, foodhorne transmission, 251 235
Sample collection errors, exposure Sniog, 199
assessment, 136 Smoke, 182
Sample size, 116, 11 7t, 137 detectors, 99
Sampling inhalation, adverse effects, 316, 31 7t
multistage, 135, 1361 Smoking, indoor air polltition Irom, 207
stratified random, 135 Social support, stress response and, 147
Sampling frame, 134 Soditim carbonate, 63
Sanitarian, 47 Sodiuni hydroxide. 63
Sanitary engineer, 50 Sotia, healthy city program, 309, 310
INDEX 437
Soilborne exposure, 59, 133, 1 33t Surveys, exposure assessment, 132
helminths and, 59 Survival curves, 2-3, 31
ingestion estimation, 133, 1 33t Susceptibility markers, 131-32, 131
Solar energy, 328, 328h, 3291 Suspended particulate matter, 182, 185
Solvents annual levels, 298, 3001
in general environment and workplace, Sustainability, energy needs for, 311-12, 3121
347-49 Sustainable developnsent
in hazardous waste, 337 current focus on, 14
Sound intensity defined, 7
dose-response relationship, 120, 1 22f implications of, 8
of familiar sounds, 83t Sustainable urban ecosystem, 282
hearing loss and, 83 Sweden, coal use, 320h, 3211
measurement, 82-83
Sound level (dB(A)), 82-83, 83t Teaching methods, 404-6, 4051
Sour gas, 321 Technical expertise, environmental health
Spain, toxic oil syndrome, 111 h professionals, 401-3
Stabilization ponds, 235 Technological disasters, 395, 395t, 396, 397
Standard operating practices, control at source Temperature (ambient)
by, 153-54 extremes, health effects, 90-92
Standardized mortality ratio (SMR), 114 global, increased, 380, 380f. See also Global
Staphylococci, loodborne transmission, 251 warming
Statistical power. 116, 1171 Temperature (body), regulation. 90-91
Statistician, 50 Terrorism, 374-75
Steel processing hazards, 341 Testosterone, 64f
Stochastic effects Textiles, manufacturing hazards, 342
dose-response relationship. 127-28 Thailand, food standards and export, 263h
radiation, 86, 326-27 Three-Mile Island accident, 258, 259, 325
Stoves Threshold dose
biomass fuel, teclitiological improvements, high-risk groups, 127
317 uncertainty factors, 123, 125-27, 1251, 127f
kerosene, air pollution from, 317 Threshold effects
Strangulation, 99 dose-response relationship, 120-27,
Street foods, safety, 268h 121f-124f, 1271
Stress radiation, 86. 327
defined, 102 Threshold limit values. 366
health effects, 103 Tickhorne disease, global warming and,
occupational, 344, 362 382-83, 385h
physiological response, 103 Time-weighted average, 365
post-traumatic, 397 Time-activity diaries, 132
psychosocial, 102-3, 344 Tobacco smoke, indoor air pollution from,
response, factors affecting, 147 207
Structural adjustment programs, 45 Tolerable daily intake (TOt), 122-23, 1251
Study designs, epidemiological, 108-13, 1 09t Tolucne
Suffocation, 99 asthma from, 357b
Suicide, 100 in hazardous svaste, 337
Sulfate, health effects, 194, 196 Total dose, 138
Sulfur dioxide, 298, 299f Total exposure, 40, 128, 137-38
in air, WHO guidelines, 40t Total suspended particles, 185
concentration, trends, 206, 206f Toxic oil syndrome, 1 lib
health effects, 191t, 193-94, 193h, 1941 Toxic stibstances
Sulfuric acid, 63, 1911 bacteria-produced, 57, 250
Supportive environments for health, 9, 9h classification, 80, SOt
Surveillance systems collection from consumers, 350
health, 160-61, bIb, 162h health effects, 72h
for injtiries, 93-94 inhalation, 187, 357h
for lead poisoning. 160-61, 162h expoire estimation, 132-33, 1331
for noise-induced hearing loss, 167, 1 oSh oxygen deprivation from, 187-88
occupational health and safety, 364-65, Toxic wastes. See Hazardous wastes
3651 Toxicity testing
screening tests for, 160, 361 b acute, 75-78, 77t
438 Index
chemical hazards, 75-79, 77t Liraniu in
chronic, 77t, 78 mining, health hazards, 326
in experimental animals, 75-79 for nuclear energy, 325, 326
genotoxic short-term, 79 Urban areas
in humans, 79 air pollution, 201. 202, 202t, 298-300,
reproductive studies, 77t, 78 299f, 300f, 301h, 331
specialized studies, 771, 78-79 energy needs, 314
structure-activity relationships, 79 "Healthy Cities" approach, 306-10, 307h
suhchronic, 77t, 78 pos'erty, 297, 2981
Toxicologist, 50 psychosocial hazards, 102-3
Toxicology, developmental, 27 sanitation, 231, 233, 2331
Toxins, natural, in food, 249, 260-61 water supply, 233t
Trace elements, health effects, 1911, 198 Urban ecosystem
Transportation, energy needs, 314 basic health requirements, 282. 285-86
Trichinellosis,foodborn e transmission, 2 52b, DPSEEA framework, 282, 283h-285h
2531 sustainable, 282
Trickling filters and towers, 235 Urbanization, 297-306
Trihalomethanes, cancer and, 229h factors affecting, 294-95, 2941
Tropical parasitic disease, 57 infrastructural requirements. 297-98
Tuberculosis trends, 293, 293f, 294t
among hospital workers, 361 UVR See Ultraviolet radiation (UVR)
hottsing conditions and, 289-90
resurgence, HIVIAIDS and, 60 Valttation methods
Tumor, primary, 74 contingent, 173, 175
Turkey, Lower Seyhan Irrigation Project cost -of- illness approach, 175
environmental impact assessment, 141 h Vanadium exposure, health eflects. 198
ntalaria and, 323-24 Vapor, 186
Typhoid, transmission, 212-13, 251 Vasculitis, vibration, 85
Vector-borne disease
Ultraviolet radiation )UVR), 87-89 environmental management, 324
carcinogenicity, 769, 88 global warnting and, 382, 384h
health etfects, 88-89, 377, 3781 spread, 57, 59
ozone depletion and, 375-77, 378f Vegetable matter, combustion, mndoot air
protection against, 377 pollution from, 515
sources, 88 Vehicles
types, 375, 376f motor. See Motor vehicles
Uncertainty, sources of, 106, 1 07t nonmotorized, 301 b
Uncertainty lactors, dose-response Ventilated improved pituitary latrine, 231,
relationship, 123, 125-27, 125t, 232, 232h
1271 Ventilation
United Kingdom, industrial development, general (dilution), control at source by,
11-12 l52b, 153
United Nations local cx ha 0 st, u nit rol a long the path by,
Agenda 21, 7 154, t551
Universal Declaration of Human Rights, 8 Vibration
United Nations Conference on Human arnt and hand, 85
Settlements, 237 health eflecis, 82-8, 85
United Nations Environmental Program V/brie c/wlercme outbreaks, 382, 38 Sb
(UNEP) Vinyl chloride
Global Env i ro nnten ta I Pu j ccl, 18 and cancer, 1129
International Register of Potentially Toxic metabolistn, 709
Chenticals, 61-62 Violence
United States, air quality standards, 202, 203t intentional, 100
United States Environmental Protection political, 100
Agency (EPA), risk communication Viral disease
rules, 1 50t loodborne, 251
Universal Declaration of Huotan Rights, 8 global warming and, 383b
Unsaturated aliphatie hydrocarbons, 63 waterhorne. 225t
Upllosv anaerobic sludge blanket reactors, Viruses
235 carcinogenicity, 76h
INDEX 439
lifecycle. 56 recreational, 236-37
Vitamin A requirements, 15
deficiency, 246, 2471 water uses and, 210, 21 lb
toxicity, 247h, 247f recreational
Vitamin E, deficiency, 248 physical and chemical characteristics,
Vitamin D deficiency, 248 237
Vitamins quality guidelines, 2 36-37
and health, 247b salety, 15
requirements and sources, 244t-245t 55' 1P1Y
Volatile organic compounds, health effects, adequacy, 2 17-18, 218f
191t, 197-98 in developing countries, 2371, 239
ensuring, 2 37-41
War global trends, 218-19
health consequences, 370-75, 3701, 372b management, 240-41
military deaths, 370t protection, 227-28, 228h
refugee issues, 371, 3721) urban areas, 2331
War and Public Health, 370 taste, 217
Warfare temperature, 217, 237
biological, 373 turbidity, 217, 237
chemical, 371, 373 uses, 209-10, 211h
conventional, modern, 370-71 wastewater reuse, 235-36
guerrilla, 374 withdrawal, 217, 2181
nuclear, 373-74 Water-dispersed infections, 213
Wastewater Water pollution, 219-20
reuse, 235-36 from air, 194, 220, 2211), 322, 392-93
safeguard measures, 236 control, 2 34-36
treatment, 235 in developing countries, 220, 222h
Water. See also Sanitation development-related. 220, 221h
acidification, 194. 220, 22 lb. 322, 392-9 from direct discharge. 22 lb
algal blooms, 220, 382, 383b historical concern with, 11
biological oxygen demand, 341 industrial
chemical constituents, 215-16, 21 6f control, 234-35
acceptable daily intake, 22 5-26 public exposure, 335. 3351
guideline values, 226-27 sources. 220
color, 2 16-17 Water-privation disease, 210, 213
Water. (continued) Water-related disease, 211, 213
communicable disease associated with, Waterhorne disease, 213. 21 4h-2 I Sb, 21 4f
210-13, 212b viral, 2251
desalination, 228 Waterhorne exposure, 55t
disinfection, 230 biological hazards, 57, 58
drinking ingestion estimation, 133, 1 33t
distribution, 230-31 personal monitoring, 130-31
fluoridation, 215-16, 230 Wal erhorne pathogens, microbiological
place of use, 231 standards, 224-2 5, 225t
quality criteria, 220-27, 2231, 225t While finger disease, 85
sources. 227-28 Wind energy. 328h, 329f, 329t
storage, 230-31 Windseale accident, 2 58-59
treatment, 228-30, 229b, 230f Women
eutrophication, 220, 221 h education and training progrants, 31-32
monitoring, 61 literacy, 31
for contaminants, 22 3-24 fertility rate by, 30t
for fecal bacteria. 222-23, 2231 mortality rate for children by. 31
GEMS project, 228b occupational health and safety, 352-54
microbiological standards, 224-2 5, 2251 smoke inhalation, 316, 31 7t
odor, 217 vulnerability to environmental hazards,
pH levels, 237 29-32
quality VVoozcu, Health and the Eni'ironmnenl ( Sims),
guidelines and standards, 220-27, 223t, 30
2251, 236-37 ,Vood, conshustion, indoor air pollution front,
indicators, 163t, 341 315
pollution and, 219-20, 2211), 222h Workers' compenSation, 352
440 Index
Workers' Compensation Board, 352 Health for All policy, 5
Workiorce, importance of. 38 network initiatives, 408
Workplace, as sentinel for environmental noise guidelines, 302
hazards, 39 water quality guidelines, 220-27, 223t
Workplace Hazardous Materials Information World Resources 1998-1999: A Guide to the Global
System (WHMIS), 80 Environment, 21
World Commission on Environment and
Development (WCED), 7 Xenobiotics, metabolism and excretion, 71
World Health Organization (WHO Xenoestrogens, 64h-65h, 64f, 65-66
air quality guidelines, 40t, 202, 203t
energy priorities, 330-31 Zoonoses, 57, 273, 279
INDEX 441
text for courses h'i m1t health fri medtiisihii
students who require a comprehensive introduction to the subject. I recommend it unreservedly.
—John Last, MD, FRACP, FRCPC, .Universijy of Ottawa,
Annals of the Royal College of Physicians and Surgeons of Canada
This comprehensive interdisciplinary text draws frqm the social sciences, the natural sciences and the
health sciences to introduce students to the principles and methods of environmental health. It offers an
overview of the basic sciences needed to understand environmental health hazards, including toxicology,
microbiology, health physics, injury analysis and relevant psychosocial conCepts. It also presents a basic ,
approach to risk assessment and risk management. The first part of the hook concentrates on broad issues,
providing frameworks for the investigation and management of environmental health problems. The middle
section deepens the discussion of routes of e*posure (air quality ; water and sanitation, food and agricul-
tural issues). The final section addresses environmental health in terms of sustainable development themes
(settlements and urbanization, energy, industry, and global concerns). The final chapter focuses on ethical ,
issues and action planning. Thus, the text alms to enhanqknowledge, skills and attitudes in environmen-
tal health.
ABOUT THE AUTORS

Annalee Yassi, MD, MSc, FRCPC, is Professor and Director of the Occupational & Environmental Health
Unit, Department of Community Health Sciences, at the University of Manitoba, Canada as well as
Director-designate of the Institute of Health Promotion Research at the University of British Columbia,
Canada. Dr. Yassi is a Medical Research Council of Canada Senior Scientist and, has sat on numerous
national and international task forces, to build capaci4' in assessing and managing environmental health
risks. As a consultant for the World Health Organization, she has conducted.workshosjfrjca. europe
and the Middle East, as well as in Canada, Australia, the U.S., and Latin America, using a daft of, this text,
Tord Kjellström, Med Dr, MMEng, is Professor of Environmental. Health at the University of Auckland,
New Zealand and Director, New Zealand Environmental and Occupational Health Research Centre. He has
20 years experience as an environmental and occupational health researcberçi teacher, in Sweden,
Australia, and New Zealand and worked from 1985 to 1997 at the World Healtlirganization, Geneva, as
envirQnmental epidemiologist and Director, Office of Global and Integrated Environmental Health. In this
position he developed teaching materials and teachersI guidelines for environmental health, and this text
is a product of these activities.
Theo de Kok, PhD, is coordinator of the Environmental Health Sciences program at Maastricht University,
The Netherlands. He is .a member of the Department of Heath Risk Analysis and Toxicology, and of the
Nutrjtkui and Toxicology'Research Institute, where his research activities focus on the assessment of envi-
ronmental and occupational health risks, biomonitoring of genotoxic effects, and colorecuil carcinogene-
sis. At the Open University of The Netherlands he developed distance teaching materials in the fields of
environmental and occupational health, nutrition, and toxicology.
Tee L. Guidotti, MD, MPH, is Professor of Occupational and Environmental Medicine, Epidemiology, and
Pulnonary Medicine at Gerge Washington University Medical Center, Washington DC, where he serves
as Chair of the Department of Environmental and Occupational Health in the School of Public Health and
Health Services, and Director of the Division of Occupational Medicine and Toxicology, Department of
Medicine in the School of Medicine and Health Sciences. He continues to serve on the adjunct faculty of
the University of Alberta, where he was Killam Annual Professor.
CovhR [lb I1, B ,41 lit F NoRol
OXFORD
UN1VE11MTY PILESS
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III l l !

7FA III III lln~,T,rI

Oxford New York

Copyrighl © 2001 by the World Health Organization

l.ihrary of Congress Cataloging-in-Publication Data

This book is intended to be used as a textbook at the university level. It is basic

Winnipeg, Manitoba, Canada A.Y.

In addition, valuable assistance in assembling the material was provided by

Nature of Environmental Health Hazards, 52

Risk Assessment, 104

Risk Management, 143

Water and Sanitation, 209

Food and Agriculture, 242

Human Settlement and Urbanization, 281

Health and Energy Use, 311

Transboundary and Global Health Concerns, 368

Action to Protect Health and the Environment, 399

After studying this chapter you will be able to do the following:

BIRTH, LIFE, DEATH, AND THE ENVIRONMENT

2 Basic Environmental Health

— 1955 1975 — — 1995 ..-. 2025

HEALTH AND THE ENVIRONMENT

The Gaia Hypothesis

and accepted, these complex, compensating mechanisms seem to apply to ecosys-

Definitions of Health and Environniejit

4 Basic Environmental Health

Human Interaction with the Environment

The scale and nature of human activities

Physical and chemical environment Biological environment

6 Basic Environmental Health

Human Ability to Adapt

8 Basic Environmental Health

In the concept of supportive environments, determinants of the health of entire

• poor quality roads

Adaptation and change to improve a community's environment then require de-

Supportive Environments for Health

10 Basic Environmental Health

The Second Wave of Environmental Concern

12 Basic Environmental Health

C REQUIREMENTS FOR A HEALTHY ENVIRONMENT

14 Basic Environmental Health

Safe and Sufficient Water

16 Basic Environmental Health

MEASURING ENVIRONMENTAL QUALITY,

Measuring Environmental Quality

Measuring Human Exposure to Environmental Hazards

18 Basic Environmental Health

Determining Health Effects and Risks in Human Populations

20 Basic Environmental Health

Respiratory effects Changes in the quality of Ide

Injuries Changes in the quality of life

private organizations. Surveys in which representative sampling strategies are

PATTERNS OF ILLNESS THROUGHOUT THE WORLD

Demographic and Epidemiological Transitions

22 Basic Environmental Health

24 Basic Environmental Health

26 Basic Environmental Health

Children As much as two-thirds of all preventable diseases due to environmen-

cOMMUNICABLE ) 45.8 71.3 42.2 8.6 9.7

TubeRulosis 3.4 4.7 2.5 0.6 0.2