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Some environmental factors affecting health in the greater Accra Metropolitan area, Ghana.

Abstract A healthy environment is a pro-requisite for physically healthy human beings. Existing relationships between society, the environment, and illness are quickly altered when rapid and radical environmental change occurs. Poverty and distress, aggravated by population growth and environmental degradation, create a climate in which disease thrives. Physical and mental health must be safeguarded as carefully as possible. Prevention is more important than cure as the foundation of good health. Development activities in the health sector can only have a sustainable effect if they are part of an integrated development perspective that combats the interconnected problems of population growth, poverty, and environmental degradation. This paper examines the case of health and environmental factors in the Greater Accra Metropolitan Area (GAMA), Ghana. Chez les etre humains, un environnement sain est necessaire a une bonne sante physique. Les liens entre societe, environnement et maladie sont vite alteres lorsque surviennent des changements environnementaux rapides et radicaux. La pauvrete et la detresse, aggravees par la croissance de la population et la degradation de l'environnement, creent un climat dans lequel les maladies se developpent. On doit sauvegarder avec le meilleur soin possible la sante physique et mentale. La prevention est plus importante que les traitements puisqu'elle est la base d'une bonne sante. Le developpement d'activites dans le secteur de la sante ne peut avoir d'effet durable que s'il fait partie d'une perspective integree de combat des problemes interrelies de croissance, de pauvrete et de degradation de l'environnement. L'article examine les facteurs lies a la sante et a l'environnement dans la grande region metropolitaine d'Accra, au Ghana. Key Terms Accra, Ghana, health hazards, environmental hazards, health impacts, urban growth, developing countries Introduction Cities are the most visible evidence of population pressures on the environment. The rapid growth of urban population damages the environment in several ways. For example, as the cities spread, they convert agricultural land to industrial and residential use. Where land is scarce, urban growth can undermine efforts to increase food production (Hardoy and Satterthwaite, 1985). Similarly, large, densely settled populations produce massive, concentrated amounts of air and water pollution, overwhelming the absorptive capacity of natural ecosystems. Much of the pollution comes from industry, which is mainly located along with workers, in urban areas. Moreover, most pollution is directly related to the numbers and concentrations of people and their levels of consumption. As city size increases, the cost to maintain environmental quality--such as providing clean water, treating sewage, and handling of other wastes--also increases. Solid wastes in many cities in developing countries are left in the streets or on vacant lots, and many city residents lack basic services such as safe water and sanitary drainage systems. For the urban poor, high population densities contribute to many health problems. Tuberculosis, viral infections, and other contagious diseases spread rapidly in crowded, cramped conditions. Migrants, attracted to urban industrial areas by the hope of jobs, are forced to drink unsafe water and inhale toxic fumes since areas open to squatter settlements are often highly polluted places shunned by the more affluent. In densely populated coastal cities near polluted fishing areas, chronic intestinal and stomach disorders are common among poor families which eat local fish (Hinrichsen, 1989). The purpose of this paper is to examine some of the environmental factors that impair health within the Greater Accra Metropolitan Area (GAMA). Evidence will be adduced using the top ten causes of hospital out-patient attendance and the index of water borne diseases to specify the relationships that this study seeks to establish. The primary objective is to stimulate thought and provide grounds for reflection. Historical Accra is the national capital city of Ghana. It became the capital in 1877, when the colonial centre of administration was moved from Cape Coast. Accra is the principal centre for trade, business communications, and administration in the country. The Greater Accra Metropolitan Area (GAMA), which includes Tema and Ga Districts, covers approximately 1520 km2 of the coastal plain. Its population is estimated at 2.1 million and is, by the year 2000, expected to exceed 2.5 million (Accra Planning and Development Programme, 1990) (Figure 1). The urbanised area is approximately 420 km2. The first plan for Accra was prepared in 1944. New plans were prepared in 1958 and 1961. These plans provided for a spacious city, with well-defined roads and services at a standard in keeping with the expectations at the time. The plans did not anticipate the rapid increase in population which has overtaxed the city's old and poorly maintained infrastructure. Population and the Environment The basic goal of any development policy is to improve the quality of human life which is invariably linked with the quality of the environment. Since the United Nations Conference on Environment and Development in Rio de Janeiro in June 1992, awareness has increased that problems of the environment cannot be fully addressed without first considering population-development linkages. One outcome of the Conference, Agenda 21, was a clear response to major environment and development challenges, including the economic and social dimensions of sustainable development such as poverty, consumption, demographic dynamics, human health and settlements. It is also stressed in the final document of the United Nations International Conference on Population and Development (ICPD) held in Cairo in September, 1994 that: Pressure on the environment may result from rapid population growth, distribution and migration especially in ecologically vulnerable ecosystems. Urbanization and policies that do not recognize the need for rural development also create environmental problems (UNICPD, 1994). Meanwhile, towns and cities in developing countries are growing faster than ever before. By the year 2000, 2.2 billion people will live in the cities of the Third World (Development and Co-operation, 1996:1). Their numbers are expected to double by the year 2025. However, many of the cities in Africa, Asia and Latin America are already bursting at the seams. Some of the so-called mega-cities have more than 10 or 15 million inhabitants. Many of them live in unplanned squatter settlements, without water and electricity, in an environment of squalor, poverty, crime, and disease. Nevertheless, the cities seem to have lost none of their attraction for rural people. Although the larger share of population increases in the cities of developing countries is caused by the children of people already living there, rural-urban migration continues unabated (Development and Co-operation, 1996:1). Cities still offer improved chances of employment and education, provide better physical infrastructure, better health facilities and a more interesting life. So, as miserable as conditions in the cities often are, they are generally much better than those in the rural areas. It is an illusion to believe that the growth of the cities could be checked by concentrating the development efforts on the countryside. Urbanization The selective intrusion of European capital, especially where resources could be found, has significantly contributed to the rural-urban dichotomy in Ghana, as in other parts of Africa (Addo, 1969). In 1921, only 14 towns had over five thousand people, but by 1931 this had increased to 27 towns and to 39 by 1948 (Addo, 1969). The rate of urbanization in Ghana between 1921 and 1984 is illustrated in Table 1. Although many of Ghana's urban centres are expanding rapidly in size and population, they remain small by world standards (Table 2). Overall, Ghana is one of the world's least urbanized countries. Table 1: Degree of Urbanization in Ghana, 1921-1984 Source: Addo, 1969;1984 Population Census Report, Accra). Index 1921 1931 1948 1960 1984 Total Population 2,295,194 3,160,386 4,118,450 6,726,815 12,205,514 Total UrbanPopulation 194,080 296,053 532,053 1,151,242 3,820,326 Urban as% of Total 7.9 9.4 12.9 23.0 31.3 Population Table 2: Population of GAMA, 1960, 1970, 1984 Censuses (Source: 1984Population Census Report, Accra). Population Annual Growth Rate %District 1960 1970 1984 1960-70 1970-84 Accra 338,396 636,667 669,195 5.1 3.1Tema 27,127 102,431 190,917 14.2 4.5Ga 33,309 66,336 132,786 6.9 5.3 Total 449,430 805,343 1,292,898 6.0 3.5 Ghana has an urbanization development rate of 3.5% and a population of over 18 million. According to the latest population census report (1984), 31.3% of Ghanaians live in urban areas with the remaining 68.7% in rural areas. The rate of population growth has an impact on the urban-rural distribution. The result has been a disproportionate concentration of urban population in a smaller number of metropolitan centres and a high rate of rural-urban migration. These phenomena have implications for economic development as the youth drift into towns and cities in search of jobs and as urban infrastructure is over-stretched while the volume and intensity of generated wastes accelerate. Since Accra became the capital in the late nineteenth century, most activities supporting the government have also been relocated. Thus trade, transport and warehousing, which were the main thrust of the country's development, became headquartered in Accra. The population growth of GAMA has been very rapid, with an average annual growth rate above 3% between 1960-1984 (Table 2). The primacy of Accra as administrative, educational, industrial, and commercial centre in attracting people from all over Ghana continues to be the major force for its rapid population growth. Migration contributes over 35% of the population increase (Ghana Government, 1984). The population of the metropolis is estimated to have increased at an annual growth rate of 4.5% since the last census in 1984 (Ghana Government, 1984). The rapid population growth in the metropolitan area is beyond the capacity of agencies and organizations to provide the resources necessary to satisfy the demand for land, housing, sanitation, welfare and community services. It has also led to rapid urban sprawl and physical expansion from the municipal boundary of Accra into Ga District, which until 1960, was largely rural in character (Benneh et al., 1993). Environmental Hazards and Their Impact on Health In most Third World urban areas, environment-related diseases or accidents remain among the major causes of illness, injury, and premature death (Satterthwaite, 1993). In many urban areas, they are the leading cause of death and illness. Environmental hazards were also major causes of ill-health, injury, and premature death in cities in Europe and North America approximately 120 years ago (Wohl, 1983). The fact that this is no longer so reveals the extent to which human intervention can modify the urban environment and protect populations from hazards. Seven kinds of health hazards are common in urban environments (Satterthwaite, 1993:87-111): 1. Biological pathogens or pollutants within the environment that impair human health include pathogenic agents and their vectors and reservoirs. Examples are: pathogenic micro-organisms in human excreta; airborne pathogens such as those responsible for acute respiratory infections and tuberculosis; and disease vectors such as the malaria-carrying anopheline mosquitoes. The biological pathogens in the human environment represent the single most serious environmental problem in terms of their impact on human health (WHO, 1992). These pathogens can be classified as food borne, airborne, or water-related, according to the medium through which human infection takes place. Water borne diseases are the single largest category of communicable disease worldwide and account for more than four million infant deaths per year (WHO, 1992). 2. Chemical pollutants in the human environment include those added to the environment through human activities, for example industrial wastes, as well as chemical agents present in the environment independent of human activities. In many cities, especially in the Third World, hazardous industrial and commercial wastes are disposed of in water bodies or land sites without special provision to treat them before disposal, or without measures to ensure that they remain isolated from the environment. Reports from Third World cities of severe health problems arising from human contact with toxic or hazardous wastes are increasingly common (Hardoy and others, 1992). 3. Adequate access to basic resources for sustaining human health is dependent upon the availability, cost, and quality of the resources. This includes food, water and fuel. 4. Physical hazards include such things as high risk of flooding in houses and settlements built on floodplains, or mudslides or landslides for houses on slopes. 5. Aspects of the built environment that have negative consequences on physical or psycho-social health include overcrowding, inadequate protection against noise, and inadequate provision of infrastructure, services and common areas. 6. Natural resource degradation affects the health and livelihoods of some urban dwellers. One example is pollution by urban households of land and water used for urban horticulture and vegetables (Hardoy and Satterthwaite, 1990). 7. National and global environmental degradation has more indirect but long-term influences on human health. It includes the depletion of finite nonrenewable resources; wastes from human activities that threaten the continued functioning and stability of global cycles and systems; the increasing frequency of extreme climatic conditions; and the depletion of the stratospheric ozone layer. The first four of these hazards have a direct bearing on health and are the most pressing urban environmental problems in terms of their health impact in Africa and much of Asia and Latin America. The other hazards also influence health, although less directly (Satterthwaite, 1993). Other studies illuminate the previous findings (World Bank 1992; and WHO, 1992). Impaired health may lower human productivity and environmental degradation reduces the productivity of many resources. Links between poor health and air pollution have been suggested in studies that compared the health of people living in highly polluted urban areas to that of people living in less polluted areas. Some of these studies have shown a strong association between the incidence of respiratory infections and pollution levels (WHO, 1992). In Latin America some 2.3 million children suffer from chronic respiratory illness, and 100,000 elderly people suffer from bronchitis--all from breathing polluted air (Latin American and Caribbean Commission on Development and Environment, 1990). It is also estimated that 65 million person days of workers' activities are lost to respiratory-related problems caused by air pollution. While these are rough estimates, they give an idea of the order of magnitude of the problem. Many disease vectors live, breed, and feed within or around houses and settlements with inadequate waste disposal systems. A study by Bradley and others (1991) shows that the diseases these vectors cause or carry include some of the major causes of ill-health and pre-mature death in many cities, especially malaria caused by the anopheles mosquito. In many Third World cities, water borne diseases are among the major causes of death. It is instructive to note that diarrheal diseases account for most water related infant and child deaths in urban areas, and a high proportion of illnesses. Risk factors include overcrowding, poor sanitation, contaminated water, and inadequate food hygiene (Satterthwaite, 1993:87-111). GAMA's Environmental Problems The accelerated urbanization and industrialization of GAMA in recent years has brought in its wake problems with the disposal of household wastes and industrial effluent (Accra Planning and Development Programme, 1990). This is because the poor infrastructure available over the years has not been able to cope with the wastes generated. The situation has been aggravated by the indiscriminate discharge of untreated effluent into the lagoons and other surface water sources which drain the metropolis. Also, solid waste generated by some of these industries is used for landfill, probably without the necessary monitoring network to check the stability of the dumps (Accra Planning and Development Programme, 1990). About 32% of all Ghanaian industries are located in GAMA which covers less than 1% of the total land area of Ghana (APDP, 1990). Here environmental pollution could be ascribed to the uncontrolled disposal of both industrial and domestic wastes. Most of these ultimately reach the water bodies which carry them into near shore waters. Everyday, more than 1,000 cubic metres of solid waste and 300 cubic metres of liquid waste are generated by these industries and households. Apart from liquids and solids, gaseous wastes are also produced by some industries, especially those involved in non-metallic mineral products and cement products (Accra Planning and Development Programme, 1990). These wastes usually contain high concentrations of fluorides and particulate material which quickly settle in areas close to the emission points. Domestic and Other Wastes Problems arise in the of collection and disposal of refuse and human wastes in the metropolis (Domfeh, 1996). The practice of using human excreta, hospital wastes, sawdust and other solid wastes for land filling is considered unsatisfactory as these are likely to decompose and leach out into the already over-polluted lagoons and also into groundwater. Many forms of pollution have been found and these include trace metals (Environmental Management Associates, 1989), chlorinated hydro carbons, and tar (IOC, 1988). Accra has been turned virtually into mountains of decomposing filth with the attendant repugnant stench that brings home the message that the city is on the threshold of being inundated in waste if nothing far reaching is done to contain the situation. The propensity to generate wastes outstrips the ability to manage or effectively dispose of it. The situation was so critical in November 1994, that a Ministerial Oversight Committee was formed to help find solutions to waste and sanitation problems in GAMA. Health Implications Table 3 shows the top ten diseases reported for hospital out-patient department attendance in GAMA in 1994 and 1995. Malaria topped the list at 39.7% of all reported disease cases for both years. In addition, the number of malaria cases rose 7% between 1994 and 1995 from 278,121 to 298,646 cases. Cholera, while not among the top ten diseases, recorded an increase of 130% between 1994 and 1995, from 697 to 1,601 cases. Upper respiratory tract infection (URTI)--the major causative factor of which is air pollution (WHO, 1992)--increased by 2%. Table 3: Top Ten Causes of Out-patient Department Attendance in GAMA Disease Number of Reported Cases 1994 % Total 1995 % Total Malaria 278,121 39.7 298,846 39.7Upper respiratory tract infection 76,254 10.9 77,765 10.3Skin disease 49,074 7.0 61,694 3.2Accidents 34,807 5.0 33,497 4.4Diarrheal diseases 34,565 4.9 33,270 4.4Pregnancy related 22,467 3.2 25,295 3.4Hypertension 18,739 2.7 17,997 2.4Oral cavity 16,793 2.4 17,214 2.3Acute eye 15,522 2.2 16,958 2.3Gyanae disorder 11,557 1.7 11,510 1.5Total Top 10 557,899 79.5 593,846 78.9All others 143,596 20.5 159,207 21.1 Grand Total 701,495 100.0 753,053 100.0 Table 4 shows the top ten causes of out-patient department attendance for Kintampo District, a rural community in Ghana. A comparative analysis of Tables 3 and 4 shows a higher incidence of URTI in GAMA than Kintampo District. In GAMA, URTI is second to malaria and forms 10.9% and 10.3% of all reported cases in 1994 and 1995, respectively. Table 4: Top Ten Causes of Out-patient Department Attendance in KintampoDistrict (Source: District Medical Officer of Health, Kintampo District, 1996). 1994 No. ofDisease Cases % total Malaria 6,067 32.8Diarrhoeal Diseases 1,219 6.6Accidents 1,015 5.5Skin diseases 816 4.4Intestinal worms 675 3.7URTI 394 2.1Gynae disorder 317 1.7Pneumonia 311 1.7Acute eye 257 1.4Measles 164 0.9Total Top 10 11,235 60.8All others 7,243 39.2Grand Total 18,478 100.0 1995 No. ofDisease Cases % total Malaria 8,854 36.4Diarrhoeal Diseases 1,178 4.9Intestinal worms 1,123 4.6Accidents 1,076 4.4Skin diseases 1,012 4.2URTI 994 4.1Pneumonia 776 3.2Pregnancy related 538 2.2Gynae disorder 441 1.8Anaemia 403 1.6Total Top 10 16,395 67.4All others 7,932 32.6 Grand Total 24,327 100.0 It is likely that the relatively high incidence of URTI in GAMA is caused by air pollution. It is also instructive to note that the top five causes of out-patient department attendance in the study area, excluding accidents, are due to infections and/or infestations which are closely associated with insanitary environmental conditions. Ababio (1992) and Songsore (1992) reinforce this assertion by stating that the major health problems in GAMA still remain preventable and communicable diseases are diseases attributable to poor environmental sanitation, ignorance, and poverty. Water supply in some parts of GAMA has remained unsatisfactory over the years (Table 5). In Accra and Tema districts, 95% and 78% of residents respectively, have access to safe drinking water, while only 39% in Ga District have potable water facilities (Ministry of Health, 1993). It is a matter of course that water borne diseases are prevalent in some parts of GAMA, especially in the Ga District. Some of the diseases identified are diarrheal diseases, intestinal worms, cholera, and so on. In 1995, 1,248 cages of cholera were reported in the Ga District--the only District where cholera is among the top five causes of outpatient department attendance in GAMA. Table 5: GAMA Communities with Safe Drinking Water (Source: 1993 AnnualReport, Ministry of Health Greater Accra Region) District % of Communities with % of Population with Safe Safe Drinking Water Drinking Water Accra 95.0 95.0Tema 78.0 78.0 Ga 39.0 39.0 In a survey by Songsore and McGranaham (1993:10-34) it was found that although most households rely on the piped system for their water supply, the distribution pattern remains uneven and the supply erratic throughout the system. Only 35% of the households had access to in-house piping. About 24% had to depend on private standpipes with another 8% relying on communal standpipes as their source of drinking water. More than a quarter of the households--28%--had to rely on informal water vendors for their daily water supply. The most disadvantaged households with regard to access to potable water were the 4% whose main source of supply was from open water ways, rainwater collection, wells and other private sources (Songsore and McGranaham, 1993:10-34). In a study by the Ministry of Health in GAMA, 46.4% and 16.2% of houses sampled in 1993 and 1994, respectively, contained "nuisances" (Table 6). Common nuisances included: human excrement on premises; overgrown weeds; accumulation of refuse; waste water left in catch pits; and, unsanitary drains resulting in the breeding of mosquito larvae--the main cause of malaria. This disease accounts for about 40% of out-patient department attendance in the study area. Table 6: Premises Containing Nuisances, GAMA (Source: Annual Report,Ministry of Health, Greater Accra Region, 1993, 1994). Nuisance 1993 1994 Number of houses inspected 42,368 60,609Number of houses with nuisances 19,639 9,819 Number of houses with mosquito larvae 1,007 1,050 In the same study, the Ministry identified that 70% of residents in Accra and Tema Districts and only 30% in Ga District have access to toilet facilities, a situation that encourages open range defecation in spaces such as the beaches. Main Victims The people who are most vulnerable to environmental hazards are those least able to avoid them and/or least able to cope with the illness or injury they cause. Ironically, dangerous or polluted land sites can serve poor groups well. For these are the only sites that are well-located with regard to income-earning opportunities and on which they have some possibility of living--albeit illegally-- because the environmental hazards make the site unattractive to other potential users. It was the high concentration of low-income residents around the Union Carbide factory in Bhopal that resulted in several thousand deaths and over 50,000 serious injuries (Centre for Science and Environment, 1985). In most urban centres, poorer groups face the most serious environmental hazards and the least possibility of avoiding them or receiving treatment to limit their health impact. At least 600 million urban dwellers in Africa, Asia and Latin America are estimated to live in "life and health-threatening" homes and neighbourhoods because of the hazardous effects of waste (Hardoy, and Satterthwaite, 1990; and WHO, 1992). Women are more vulnerable than men to many environmental hazards, according to a report by the World Health Organization (WHO, 1992). Some because of their sex, that is, as a result of biological differences; and some because of gender, that is, as a result of the particular social and economic roles that women have, as determined by social, economic, and political structures. Pregnant mothers, like their foetuses, are particularly vulnerable to certain environmental hazards. The report notes: The reproductive system is particularly sensitive to adverse environmental conditions. Every stage of the multi-step process of reproduction can be disrupted by external environmental agents and this may lead to increased risk of abortion, birth defects, fetal growth retardation and perinatal death (WHO, 1992). Women's vulnerability to all environmental hazards is linked to sanitation, drainage and refuse collection and to the practical needs of those responsible for child care and household management who are overwhelmingly female. These people are rarely given the priority they should have in government provided services or housing programmes. The extension of the health burden imposed by the changing environment on urban populations remains poorly understood. It is almost certainly underestimated, not only because of little data but also because it is usually the result of the environmental problems operating concurrently with many non-environmental problems. Some caution is needed in predicting the likely impact on health of environmental improvements. An analysis of the causes usually points to a wide range of factors--environmental, social, political, genetic and so on--and it is difficult to separate the relative role of one from the others (Bradley and others, 1991). While environmental modifications are often among the most effective ways of diminishing the health impact of communicable diseases, other factors need to be addressed. For instance, malnutrition is among the most serious health problems for most poor urban populations. Concluding Remarks The current environmental problems in GAMA can, in part, be explained in terms of past urban development practices that have damaged the natural and urban environments. Because of the continuing concentration of population, industrial activities, congestion, and untreated domestic and industrial waste and effluent, further degradation of the natural environment is inevitable. Concern about safety of the environment keeps growing as discharges from industries are normally untreated. Pollution problems continue to mount as populations move to the metropolis seeking greater opportunities. In the midst of mass poverty and processes of disintegration, short-term individual interests--whether related to daily survival or quick profit--take precedence over environmental and health concerns. In GAMA, diarrhoeal problems provide a very clear example of the wealth-environment-health connections. The environmental risk factors found to be associated with a high prevalence of childhood diarrhea read like a list of poverty indicators: overcrowded toilets (because each is shared by many households); fly infestation; interruptions to water supplies; questionable water shortage practices; and children practicing open defecation in the neigbourhood (Songsore and McGranaham, 1993:10-34). In addition to health criteria developed by the World Health Organization (WHO), it is imperative that specific standards also be developed and applied in GAMA. Improved indigenous knowledge of health, illness, and its linkages with environmental conditions seems to be especially important in establishing sensible priorities and formulating the best possible health policy. Consequently, environmental education programmes, both formal and informal, should be instituted. The objective should be to increase awareness, expand knowledge, improve attitudes and habits and influence decision making. The curriculum should include public health, natural resources, population dynamics, human settlement and environmental management. Finally, it is recommended that hospital records on diseases in the metropolis should be kept not only on the basis of attendance at health institutions, but also according to locality of patients. This can improve understanding of the spatial patterns of morbidity in the area and their likely causes, in turn leading to improved education, policy and practice, and greater capability in health planning. References Ababio, Beneficta M. 1992. Urban Primary Health Care: Accra Healthy Cities Project. Ministry of Health: Accra. Accra Planning and Development Programme. 1990. Strategic Plan for the Greater Accra Metropolitan Area. Vol. 1 (Draft). Accra. Addo, N.C. 1969. Dynamics of Urban Growth in South-East Ghana. 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Date:Jan 1, 1999
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