International environmental health: priorities from Huairou.

Editor's note: Though the majority of information presented in the Journal is based on situations within the United States, environmental health and protection know no boundaries. The Journal will periodically run an International Perspectives column to ensure that the issues relevant to our international constituency, representing over 60 countries worldwide, are addressed. It is our goal to present issues of interest and diversity to all of our readers, irrespective of origin. In offering perspectives from abroad, whether research or commentary, this column will also serve to keep you informed of international environmental health concerns. It is designed to explore problems and solutions from all parts of the world that could be helpful to you.

Introduction

Between August 30 and September 8,1995, 38,000 women and several hundred men gathered in Huairou, China, to discuss the global status of women and to lobby for specific wording in the Agenda for Women that was being finalized in Beijing. The meeting in Beijing, called the United Nations Fourth World Conference on Women, comprised governmental representatives. while the meeting in Huairou included primarily representatives from nongovernmental organizations (NGOs) and was called the "NGO Forum on Women." The NGOs ranged from grassroots organizations working with communities to improve local educational, environmental, and social conditions to multinational organizations whose efforts focus on problems that cross international boundaries, such as refugee health, the stature of women in international policy-making groups, and global environmental pollution. Women and men from approximately 200 countries representing hundreds of NGOs attended the forum. The stated goal of the NGO forum was "to bring together women and men to challenge, create, and transform global structures and processes at all levels through the empowerment and celebration of women" (1).

Approximately five percent of the activities and presentations in Huairou focused on the environment, and an additional 10 percent focused on health (2). These two topics covered a wide variety of issues ranging from residential safety to ecosystem integrity, and from prenatal health to gerontology.

This article has two objectives: The first is to summarize the priority concerns identified in Huairou that are related to international environmental health, especially concerns related to women. The second objective is to provide the rationale and documentation that support including these topics as part of professional education and practice in environmental health in the United States.

"International environmental health" is defined broadly as environmental health that incorporates the perspectives and needs of economically developing countries, as well as the prevention and control of global environmental exposures that affect human health, into its professional agenda. Seven areas of priority concern were assembled from a review of the "Schedule of Activities" for the NGO forum, from observations that one of the authors (Annette Rossignol) made while attending the forum, and from discussions with other forum attendees. The seven areas of priority concern were

1. poverty and environmental degradation,

2. housing,

3. environmental toxicants,

4. water,

5. population,

6. HIV/AIDS and tuberculosis, and

7. environmental policy and decision making.

Although the nature and focus of the concerns related to these areas differed somewhat among participants from different countries and sometimes even among participants from different regions within a country - there was, overall, substantial agreement among forum participants, including participants from the United States, about the global importance of each of these topics.

Poverty and Environmental Degradation

Forum attendees regarded poverty and environmental degradation as highly connected. Excessive, unsustainable consumption by economically developed countries was seen as a major cause both of poverty and of environmental degradation. This position has been argued by others and is supported by the fact that approximately 20 percent of the world's population, living in economically developed countries, consumes at least 70 percent of the natural resources (3,4). The United States, alone, with about five percent of the world's population, produces one-quarter to one-half of all industrial wastes (5). Poverty also can cause environmental decline when poor people overexploit their environments in attempts to provide for families by growing crops, grazing livestock, and otherwise living and working on marginal lands (6). Deterioration of the environment was of particular concern to rural and agricultural women, for whom destruction of environmental systems often results in displacement from income-generating activities.

Environmental degradation and the initiation of war and other civil strife, as well as environmental degradation and refugee status, were seen as causally related to one another. This view, again, is a position for which there are ample supporting data (7,8).

Housing

Concerns related to housing included lack of adequate housing and the pervasiveness of homelessness, lack of opportunities for orphans and street children, lack of funds to improve slum dwellings, and the need for improved programs and policies to reduce the pandemic of environmental refugees.

Worldwide, approximately one person in every 123 is displaced (7), amounting to 27 million people who are international refugees and an additional 20 million people who are refugees within their own national borders (9,10). Additional millions of people live in makeshift or otherwise inadequate housing. Refugees, the majority of whom are women and children, suffer not only loss of housing, economic well-being, and educational opportunities, but also loss of their relation to the larger cultural and structural environments in which they once lived (11).

Strategies to prevent excess mortality in refugee populations urgently are needed. Among infants and children, excess mortality can rise to over 60 times the expected mortality (12). Infectious diseases that are amenable to control through the application of basic environmental health principles are responsible for many of these excess deaths (12).

Prevention and Control of Environmental Toxicants, Particularly Toxins That Disproportionately Affect Women and Children

Several concerns related to environmental toxicants were identified in Huairou, including

* a perceived overuse of pesticides that has resulted in reduced food and breast milk safety,

* the increasing incidence of environmentally-caused cancers and especially cancers associated with the use and release of chemical carcinogens, and

* the creation of toxic wastes by developed countries and the export of these wastes to developing countries.

A concern, common to each of these areas, is the fact that fetuses and infants, whose cells are dividing rapidly, constitute a subpopulation that is particularly sensitive to many environmental toxicants. As an example, the organic form of mercury, methylmercury (MeHg), is highly lipid soluble and bioaccumulates in fatty tissues. Thus, pregnant women can serve as reservoirs, passing MeHg to the fetus via placental transfer or during breast-feeding.

Blood levels of MeHg in fetuses exposed in utero can be several times higher than in maternal blood. Importantly, adverse effects in infants and neonates have been shown to occur at levels that are not overly toxic to the mother (13). For example, during the MeHg epidemic in Minamata, Japan, some of the fetuses who were exposed in utero later developed severe mental retardation, while their mothers were asymptomatic or only mildly affected (13). A major route of exposure to MeHg, as wall as to other lipid-soluble toxicants, is fish consumption. For example, elevated blood levels of MeHg have been documented in indigenous populations who are dependent on fish as a primary food source (14-16).

The nature and severity of the potential nervous system changes vary according to the duration and intensity of MeHg exposure and according to the gestational stage at which exposure occurs. The critical periods for MeHg exposure during pregnancy appear to be the late embryonic and fetal periods, after the seventh week of gestation (13,17-18). On the basis of studies of exposed populations, ingestion of 0.7 micrograms ([[micro]gram]) of MeHg per kilogram of body weight per day is considered to be the lowest observed-effect level (LOEL) for neurological effects in the developing brain (19).

An emerging environmental health threat is widespread exposure to environmental chemicals, known as environmental estrogens, that disrupt endocrine and reproductive function. Recently, hormone mimics have been detected in environmental samples, and altered sexual and reproductive success have been reported for some wildlife species (20-22). Some environmental estrogens, such as phytoestrogens, occur naturally, while others, such as alkyl phenols found in municipal sewage treatment plant discharges or in DDT and its breakdown product, DDE, are anthropogenic. Endocrine disrupters alter the hormonal cycle, affecting sexual development, and could ultimately affect reproductive success (23).

The significance of low-level human exposure to endocrine disrupters such as pesticides and dioxins currently is a vigorously debated topic among environmental health scientists (22,24). Diet appears to be the major route of exposure to these hormonally active compounds, and elevated levels have been detected in estrogen-sensitive tissues, such as the breast and vagina, of women with cancers at these sites (25).

Water

In Huairou, the major concerns related to water were the guarantee of safe and convenient potable water supplies, the availability of water for sustainable agriculture, and mitigation of the effects of drought (26). In most economically developing countries, each of these problems disproportionately affects women and children; women and children generally are responsible for the physical tasks of locating and transporting water for drinking, for household needs such as cooking and laundry, and for agricultural and other husbandry needs. Often these tasks involve walking many miles to a water source and then returning, carrying heavy containers of water.

At least 1.5 billion people, many of whom live in rural areas, lack access to safe drinking water (27). Worldwide, the most serious water pollutants in terms of human health are pathogenic organisms that cause typhoid, cholera, bacterial and amoebic dysentery, enteritis, polio, infectious hepatitis, and schistosomiasis. The major source of pathogens is untreated or improperly treated human waste. Animal waste also significantly contributes to the contamination of drinking-water sources.

A recent World Development Report estimates that diarrheal diseases caused by contaminated water kill approximately two million children and cause approximately 900 million episodes of illness each year (28). In addition, it has been estimated that, globally, as many as 80 percent of all cases of infectious diseases are related to contaminated water (29).

In more economically developed countries, pathogenic contamination of drinking water supplies is rare, although large outbreaks of, for example, cryptosporidiosis, have occurred. Drinking-water contamination in developed countries is more likely to be associated with the presence of low levels of organic or inorganic industrial or agricultural pollutants such as perchloroethylene, trichloroethylene, trihalomethanes, pesticides, nitrates, arsenic, and mercury. Long-term exposure to low levels of these environmental chemicals may increase the risks of cancer or of other adverse health effects in human beings. Improved identification and measurement of these chemicals is attributable to the increased sensitivity of analytical methods of detection.

Population

Of considerable concern among forum attendees was the implementation of certain governmental and international policies that focus on population. In particular, forum attendees were concerned about the International Monetary Fund's (IMF's) and the World Bank's "structural adjustment" programs that link financial aid to a country's implementation of specific population and economic policies. These programs were perceived as having substantial, negative effects on women and children by undercutting the availability of local funding to support environmental, educational, and health services and programs for women and children; by reducing employment opportunities and access to credit; and by institutionalizing population programs that do not respect the rights of women (30,31). The overall effect of the structural adjustment programs has been the movement of millions of women and children into poverty (32). Interestingly, the World Bank and IMF recently have reconsidered their positions concerning the benefits of structural adjustment programs.

In addition, as mentioned previously, forum attendees viewed overconsumption, not overpopulation, as the underlying cause of worldwide environmental degradation. The rationale for this view is the relative overuse of natural resources by economically developed countries compared with use by economically developing countries (4).

Discussions at the forum concerning family size emphasized the position that determination of family size is a personal choice of each woman (33). Of interest was the relationship between improved education for women and reduced family size (34-36). Changes in population age pyramids in many regions of the world, which are being caused by increasing life expectancy in conjunction with decreasing fertility, also were considered (37).

HIV/AIDS and Tuberculosis

Forum attendees uniformly were concerned about the current pandemic of HIV/AIDS and its relation to other diseases such as tuberculosis (38). Approximately one-third of the world's population currently is infected with tuberculosis (39). In many countries, tuberculosis is the leading cause of death among children who are infected with HIV.

Worldwide, funds to support HIV/AIDS programs have been diverted from funding for other local programs, including programs for the environment, agriculture, and health. In addition, when HIV/AIDS affects a family, the adult males typically die from AIDS or from AIDS-related diseases before the adult females die. As a result, AIDS has a broad-reaching impact on the economic viability of the family unit, forcing millions of women, children, and elderly relatives into poverty (40-42).

Inclusion of Women in Environmental Policy Formation and Decision Making

As Rodriguez-Trias discusses, a critical first step toward achieving a coherent vision for the global environment is ensuring the full participation and partnership of women in all discussions concerning population, development and environment (3). Inclusion of women in this dialogue is imperative because, worldwide, women receive 10 percent of the income and own 10 percent of the property but do 65 percent of the work and grow 90 percent of the crops, including 60 percent of the cash crops. Historically, women have been excluded from participating in these discussions, even in discussions concerning population (43). In many regions of the world, women primarily are responsible for environment-related family tasks such as providing for cooking and heating fuel, collecting water, gathering and cooking food, and managing solid wastes. Clearly, how a woman performs these tasks and whether she does so with a longer-term, environmentally beneficial plan affects the level of environmental health she, her family, and her community enjoy. Input and leadership from women on environmental health issues are necessary to develop environmental policies and programs that succeed on local, regional, and global levels.

Concluding Remarks and Recommendations

The seven areas of international environmental health identified by participants of the Forum on Women in Huairou should be incorporated into environmental health education and practice both in the United States and elsewhere. While some environmental health professionals may choose not to work in an international setting, they nonetheless need to understand how global environmental health issues are connected to local environmental health problems. Furthermore, a better understanding of the applicability of gender-related environmental health concerns will improve local programs, policies, and infrastructure.

Our recommendations for incorporating international environmental health concerns - especially concerns related to women and children - into professional education and practice are as follows:

1. Incorporate instructional material concerning international environmental health, and especially issues related to gender, into undergraduate and graduate educational programs in environmental health in the United States and elsewhere.

2. Evaluate and include, as appropriate, the distinct impact on women and children of environmental health laws and regulations.

3. Following the federal Women's Health Initiative, include women and children, as appropriate and ethical, in environmental health research.

4. Include concerns related to poverty, violence, and population - and their impacts on women and children - as part of the purview of the environmental health professional.

5. Ensure, through appropriate legal approaches and/or practice norms, the participation of women in the creation and implementation of environmental health policy.

Adoption of these recommendations would make an important contribution toward addressing the seven areas of priority concern highlighted in Huairou. It also would improve the public's environmental health.

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Corresponding Author: Annette MacKay Rossignol, The Department of Public Health, Oregon State University, Corvallis, OR 97331-6406.