Epidemiology, Economics, Experiences ENVIRONMENT AND DEVELOPMENT Environmental Health and Child Survival Environmental Health and Child Survival ENVIRONMENT AND DEVELOPMENT A fundamental element of sustainable development is environmental sustain- ability. Hence, this series was created in 2007 to cover current and emerging issues in order to promote debate and broaden the understanding of environ- mental challenges as integral to achieving equitable and sustained economic growth. The series will draw on analysis and practical experience from across the World Bank and from client countries. The manuscripts chosen for publi- cation will be central to the implementation of the World Bank’s Environment Strategy, and relevant to the development community, policy-makers, and academia. Topics addressed in this series will include environmental health, natural resources management, strategic environmental assessment, policy instru- ments, and environmental institutions. Also in this series: International Trade and Climate Change: Economic, Legal, and Institutional Perspectives Poverty and the Environment: Understanding Linkages at the Household Level Strategic Environmental Assessment for Policies: An Instrument for Good Governance Epidemiology, Economics, Experiences Environmental Health and Child Survival © 2008 The International Bank for Reconstruction and Development/The World Bank 1818 H Street, NW Washington, DC 20433 Telephone 202-473-1000 Internet www.worldbank.org E-mail feedback@worldbank.org All rights reserved. 1 2 3 4 :: 11 10 09 08 This volume is a product of the staff of the International Bank for Reconstruction and Development / The World Bank. The findings, inter- pretations, and conclusions expressed in this volume do not necessarily reflect the views of the Executive Directors of The World Bank or the governments they represent. The World Bank does not guarantee the accuracy of the data included in this work. 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All other queries on rights and licenses, including subsidiary rights, should be addressed to the Office of the Publisher, The World Bank, 1818 H Street NW, Washington, DC 20433, USA; fax: 202-522-2422; e-mail: pubrights@worldbank.org. ISBN-13: 978-0-8213-7236-4 eISBN-13: 978-0-8213-7237-1 DOI: 10.1596/978-0-8213-7236-4 Library of Congress Cataloging-in-Publication Data Environmental health and child survival : epidemiology, economics, expe- riences. p. ; cm. — (Environment and development) Includes bibliographical references and index. ISBN 978-0-8213-7236-4 1. Environmentally induced diseases in children Developing countries. 2. Malnutrition in children Developing countries. I. World Bank. II. Series: Environment and development (Washington, D.C.) [DNLM: 1. Child, Preschool. 2. Environmental Health. 3. Cost of Illness. 4. Developing Countries. 5. Disorders of Environmental Origin. 6. Malnutrition. WA 30.5 E605 2008] RJ383.E583 2008 618.92'98 dc22 2008022136 Cover photo: World Bank Photo Library Cover design: Auras Design, Silver Spring, Maryland CONTENTS xi Acknowledgments xiii Abbreviations and Acronyms CHAPTER 1 1 Introduction 4Objectives 5 Audience 5 A Primer on Environmental Health 6 A Primer on Malnutrition 7 Content and Organization PART I 15 Epidemiology CHAPTER 2 17 Environmental Health, Malnutrition, and Child Health 18 Environmental Factors, Exposure, and Transmission Pathways 19 Vicious Cycle of Infections and Malnutrition 23 Environmental Role in Early Childhood Health 28 Averting Cognition and Learning Impacts 30 Key Messages 30 Note CHAPTER 3 31 How Environmental Health Supplements Other Child Survival Strategies 32 Adding Value to Health Systems 38 Adapting Environmental Management Programs 39 Adjusting Infrastructure Strategies 43 Key Messages 43 Notes PART II 45 Economics CHAPTER 4 47 How Large Is the Environmental Health Burden? 48 Burden of Disease 51 Environmental Health Burdens 58 Areas for Future Research v 59 Key Messages 59 Notes CHAPTER 5 61 Estimating the Environmental Health Burden and Costs at the Country Level 61 Existing Practice in Environmental Health Valuation 62 Building New Estimates for Environmental Health Costs 64 Case Studies of Ghana and Pakistan 66 Results for Ghana and Pakistan 77 Conclusion 79 Next Steps 81 Key Messages 81 Notes PART III 83 Experiences CHAPTER 6 85 Approaches to Environmental Health 86 History of Environmental Health 88 Agenda Falling through the Cracks 90 Environmental Health Experiences in Developing Countries 97 Understanding the Enabling Environment 100 Governance and Institutional Implications 104 Institutional Requirements for Successful Environmental Health Governance 109 A Critical Moment 109 Key Messages 110 Note CHAPTER 7 111 Conclusion 111 Contributions of This Report 113 Next Steps Appendixes 117 APPENDIX A: Technical Review of Cohort Studies 117 Background 118 Search Strategy and Selection Criteria 118 Findings and Discussion 122 Experimental Evidence from Deworming 123 Conclusions 125 Notes 141 APPENDIX B: Review of Studies on Nutritional Status and Education 145 Diarrhea and Education vi CONTENTS 145 Conclusions 146 Note 147 APPENDIX C: New Estimates for Burden of Disease from Water, Sanitation, and Hygiene 151 APPENDIX D: Computing Country-Level Environmental Health Burden of Disease 151 Mortality 160 Education 170 Notes 173 APPENDIX E: Methodological Aspects of Assessing Environmental Health Burden of Disease 173 From Relative Risks to Attributable Fractions 176 Dealing with Biased Estimates of Relative Risk 177 Notes 179 APPENDIX F: Monetary Valuation of the Cost of Environmental Health Risks 181 Note 183 References 201 Index Boxes 2 1.1 What Is Environmental Health? 22 2.1 Impact of Diarrhea on Child Malnutrition: Evidence from Research 25 2.2 Overweight Mothers Carrying Underweight Children 50 4.1 Why 50 Percent? Supporting Evidence from Recent Cohort Studies 54 4.2 Revisiting the “Asian Enigma” 56 4.3 The Mills-Reincke Phenomenon 65 5.1 Basic Indicators for Ghana and Pakistan 75 5.2 Attributable Fractions and Burden of Disease When Multiple Risk Factors Are Present 80 5.3 How Policy-Makers Should Interpret These Results 87 6.1 Combating Disease through Improved Milk 92 6.2 Mexico: Multisectorality through a Diagonal Approach 93 6.3 Thailand’s National Nutrition Program 95 6.4 Ethiopia: The Toilet Revolution 97 6.5 Vietnam’s Dengue Program 101 6.6 Atrophy of Environmental Health Functions in India 102 6.7 Institutional Evolution of Environmental Health: The Case of Ethiopia Figures 19 2.1 The F-Diagram: Transmission Routes for Infection 20 2.2 Relationship between Nutrition and Infection CONTENTS vii 24 2.3 Environmental Health Inputs and Health Outcomes in the Child’s Life Cycle 27 2.4 The Window of Opportunity for Addressing Undernutrition 32 3.1 Range of Preventive Activities in Child Survival 52 4.1 The Health Effects of Environmental Risks Factors 53 4.2 Water-Related (WSH plus WRM) Burden of Disease in Children under Five Attributable to Environmental Risk Factors by WHO Region, 2002 55 4.3 Mills-Reincke Ratios for Subregions 63 5.1 Cost of Environmental Health Risks 70 5.2 Weight-for-Age Distribution of Children in Ghana and Pakistan 71 5.3 Two-Week Diarrheal Prevalence Rate by Age and Underweight Status in Ghana and Pakistan 73 5.4 Underweight Malnutrition Rates in Children with and without Diarrheal Infections in Ghana and Pakistan 74 5.5 Calculating Revised Estimates (Indirect and Direct Effects) 78 5.6 Final Results of Ghana and Pakistan Case Studies 152 D.1 Summary of the Methodology 155 D.2 Exposure Categories 159 D.3 Exposure Categories, Population Shares, and Relative Risks of ALRI in Ghana Tables 3 1.1 Millennium Development Goals and Environmental Health 10 1.2 Annual Cost of Direct and Indirect Impact of Environmental Risk Factors in 2005 18 2.1 Water-Related Transmission Routes and Disease Outcome 21 2.2 Impact of Infection on Nutritional Status 33 3.1 Role of Environmental Health in Supplementing Health System Strategies 49 4.1 Environmental Risk Factors and Related Diseases Included in the Comparative Risk Assessment 67 5.1 Environmentally Attributable Fractions of Child Mortality, Keeping Malnutrition Unchanged 67 5.2 Estimated Mortality in Under-Five Children from Environmental Risk Factors, 2005 68 5.3 Malnutrition Rates in Children under the Age of Five 70 5.4 Malnutrition-Attributable Fractions of Child Mortality 74 5.5 Environmentally Attributable Fractions and Child Mortality with Malnutrition-Mediated Effects 76 5.6 Effects of Malnutrition on Education 79 5.7 Annual Cost of Direct and Indirect Effect of Environmental Risk Factors in 2005 126 A.1 Cohort Follow-up Studies Relating Infectious Disease and Nutritional Status of Children in Developing Countries 142 B.1 Studies of the Effects of Malnutrition on Educational Outcomes viii CONTENTS 148 C.1 Burden of Disease (in DALYs) in Children under Five Years Attributable to Water, Sanitation, and Hygiene, by World Health Organization Subregions, 2002 152 D.1 Causes of Death and Risk Factors Considered in this Study 154 D.2 Estimating the Cost of Environmental Health Risks: Information Types and Sources 156 D.3 Relative Risks by Exposure Categories, Assuming Cox Hazard Model 157 D.4 Weight Gain Retardation Factors by Age and z-Score 158 D.5 Weight for Age in Children under Five: Current Rates and Estimated Rates in the Absence of Diarrheal Infections in Ghana 159 D.6 Estimated Mortality in Children under Five from Environmental Risk Factors, Ghana 161 D.7 Estimated Annual Cost of Education Outcomes from Stunting and Share from Environmental Factors in Ghana 162 D.8 Height Growth Retardation Factors by Age and z-Score 162 D.9 Height-for-Age Rates in Children under Five: Current Rates and Estimated Rates in the Absence of Diarrheal Infections in Ghana 165 D.10 Parameter Values Applied in Estimation of Income Losses 167 D.11 Income Distribution across Malnutrition Categories and Wealth Quintiles in Ghana 168 D.12 Annual Cost of Environmental Factors (Percentage of GDP in 2005), Using 3 Percent Discount Rate 169 D.13 Annual Cost of Environmental Factors (Percentage of GDP in 2005), Using 5 Percent Discount Rate 174 E.1 Environmental Risk Factors and Related Diseases Included in the WHO Comparative Risk Assessment CONTENTS ix [...]... million children every year; most of those deaths are attributed to contaminated water and inadequate sanitation and hygiene (WHO 2007b) Each year, approximately 300 million to 500 million malaria infections 1 2 ENVIRONMENTAL HEALTH AND CHILD SURVIVAL BOX 1.1 What Is Environmental Health? Environmental health is defined as those health outcomes that are a result of environmental risk factors The World Health. .. concerted and continuous effort is needed on behalf of both developed and developing countries to ensure that environmental health is placed high on the development agenda, and corresponding interventions must be financed and undertaken to improve children’s survival and development potential P A R T I Epidemiology C H A P T E R 2 Environmental Health, Malnutrition, and Child Health MALNUTRITION, POOR ENVIRONMENTAL. .. and collaborative way A Primer on Environmental Health Environmental health relates to human activity or environmental factors that have an impact on socioeconomic and environmental conditions with the potential to reduce human disease, injury, and death, especially among vulnerable groups—mainly the poor, women, and children under five (Listorti and Doumani 2001; Lvovsky 2001) The top killers of children... the third describes the experiences of environmental health actions in developing countries Each section strives to present the latest information and data and highlights the reasons environmental health is so critical in the context of child survival and development Epidemiology Chapter 2 argues that improvements in environmental health are very important for child survival and development, especially... improved understanding of the links between environmental health risks and malnutrition through a review of literature and research Moreover, the study discusses the role of environmental health inputs in a child s survival and growth ■ To analyze new data for the environmental health burden of disease (at a subregional level) that relates to children under five These data, which are from a World Health Organization... neglect of environmental health in the development agenda Environmental health actions are the earliest public health activities on record Lessons from history have shown the enormous benefits of multisectoral environmental health actions, with today’s developed countries having undergone an evolution in environmental health functions However, both institutionally and conceptually, environmental health. .. Africa and South Asia, where poor environmental conditions and high malnutrition prevalence coexist—should be especially targeted to fund and implement environmental 12 ENVIRONMENTAL HEALTH AND CHILD SURVIVAL health interventions The multiplier effect of such interventions points to the potential of their significant health externalities At a country level, the burden of disease associated with environmental. .. countries and who are involved in designing policies for and allocating resources to programs that contribute toward improving child health The study will also be useful to state- and locallevel governments, because the actual implementation of programs and initiatives on child health is at the level of communities and households Furthermore, donors and other organizations financing child health improvement... from environmental factors and to the associated economic costs Measuring the burden of disease and subsequent economic costs from environmental health risks is important in helping policy-makers better integrate environmental health into economic development and, specifically, into their decisions relating to the allocation of resources among various programs and activities to improve child health. .. estimates and taking into consideration the links between environmental health, malnutrition, and disease, WHO recently revised the burden of disease estimates taking into account malnutrition-mediated health impacts associated with inadequate water and sanitation coverage and improper hygienic practices (Fewtrell and others 2007) The new WHO estimates reveal that the environmental health burden in children . Epidemiology, Economics, Experiences ENVIRONMENT AND DEVELOPMENT Environmental Health and Child Survival Environmental Health and Child Survival ENVIRONMENT AND DEVELOPMENT A. Governance Epidemiology, Economics, Experiences Environmental Health and Child Survival © 2008 The International Bank for Reconstruction and Development/The