Table of Contents

HEALTH IMPACTS OF URBAN GREENING
    Nutrition
    Environmental Sanitation
HABITAT FOR DISEASE VECTORS"
    Dengue Fever
    Malaria
HEALTH IMPACT ASSESSMENT
NURSES' ROLE IN DEVELOPMENT
CONCLUSION
REFERENCES

Health Impacts of Urban Greening

Over the last 50 years many remarkable transformations have occurred in our world. One of the most significant has been the mass migration from rural to urban areas (FAO, 1999). While this has reaped many benefits, such as increased economic development and higher incomes, it has also brought with it serious environmental problems. Cities are hotter than surrounding country sides and have significant problems with flooding (E. Fraser, Project Manager of Bangkok Urban Greening, personal communication, February 15, 2001). These two facts make ideal conditions for disease to spread through densely populated, often poor communities.

One way of addressing these issues is through establishing Urban Greening Spaces. Trees and plants create microclimates of cooler temperatures through transpiration of oxygen and moisture, they hold soil in place and absorb water (Fraser, 1997). The environmental benefits of Urban Greening Spaces are well documented. What is less well understood are the health implications. This report will do two things: (1) examine the health implications and opportunities of Urban Greening projects and; (2) examine how those implications can be assessed by the Environmental and Occupational Health Impact Assessment, a tool that has been approved by the World Health Organisation (WHO), and the International Labour Organisation (ILO) for the assessment of the health impact of environmental and occupational development projects (Pastides & Corvalan, 1997).

Nutrition

Poor urban communities around the world are starving in a sea of plenty. Without the resources to buy the food needed for a well balanced diet, and being subjected to living conditions that elevate their parasitic loads that rob them of the nutrients they do ingest, the poor suffer from the effects of malnutrition while their richer urban neighbours do not. Although it is usually impossible for urban agriculture to address caloric deficiencies due to the amount of space needed to cultivate grains that make up most of our caloric intake, it can address micronutrient deficiencies that lead to night blindness, decreased intelligence and higher susceptibility to disease (Gibney, 1999). This section will focus on micronutrient malnutrition as it can be prevented through small urban gardens. Micronutrient malnutrition can be averted by including the small amounts of vitamins and minerals needed, many found in fruits and vegetables, and decreasing parasite loads that would inhibit proper absorption of nutrients.

The FAO and the International Life Sciences Institute have come together to create Preventing Micronutrient Malnutrition: A guide to food based approaches—A manual for policy makers and programme planners, an extensive manual to support planners and communities in addressing micronutrient malnutrition (FAO, 1999). The authors state the all-encompassing effects of malnutrition on the community and society thus:
Micronutrient deficiencies are a major obstacle to socio-economic development in many countries. They have an immense impact on the health of the population (with high social and public costs), learning ability (with a vast loss of human potential) and productivity (with greatly reduced work capacity). These deficiencies contribute to a vicious cycle of malnutrition, underdevelopment and poverty affecting already underprivileged groups. Children are often the victims of malnutrition, which further jeopardizes the future of their country. (FAO, 1997)

The simple act of planting banana, papaya, mango and coconut trees instead of non-fruit bearing trees can have positive effects in this area of a community’s health. By fortifying a community’s ability to meet their vitamin and mineral needs, especially that of children’s, the loss of human potential through sickness, disability or the stunting of intellectual growth can feasibly be averted, giving that community a better chance at improving their lives.

Even if the community does not have cases of clinical micronutrient malnutrition, subclinical deficiencies have an impact on the individual’s ability to fight off diseases, parasites and tumours. As Michael Gibney writes, “…the science of nutrition has moved the goal-posts away from the provision of nutrient intake merely to avoid the pathologies of deficiency, towards the concept that nutrients have disease-prevention functions at intakes above the deficiency threshold.” (1999) By having easily accessible free fruits and vegetables high in vitamins in a community garden or fruit trees, the community can not only obtain the micronutrients they need, but also be able to use the money they would have spent on these foods towards other needs.

Eliminating either overt or subclinical malnutrition have potential for sound research possibilities. By eliminating clinical deficiencies, improvements should begin to show themselves very quickly and profoundly (e.g. reduction of blindness from vitamin A deficiency, higher birth rates by eliminating iron deficiencies in pregnant women, etc.), and continue to assert themselves while nutrient levels are being met (FAO, 1999). Resolving subclinical malnutrition, although not as dramatic, may prove epidemiologically interesting by comparing rates of infection, cancer, or parasitic load in communities that are able to consume a variety of nutrient-rich foods, and those communities that do not have the benefits of such a project (FAO, 1999).

Environmental Sanitation

As mentioned above, some parasites inhibit nutrient absorption. Those that are especially threatening are those which create diarrhoeal and other intestinal problems (FAO, 1999). Many of these parasites are found in tainted water supplies and poor sanitation, a reality for millions of people (Huttly, Morris, & Pisani, 1997). Depending on the parasite, diarrhoea can cause severe losses of water, nutrients and electrolytes, and consequently, a life-threatening situation for young children (Huttly, Morris, & Pisani, 1997). According to Murray and Lopez, “Malnutrition and poor sanitation, water and hygiene are the leading risk factors for premature mortality and disability among children in developing countries” (1997). Malnutrition and diarrhoea are linked as the sufferer of diarrhoea is unable to absorb the nutrients he or she consumes, and a general level of malnutrition makes the person more susceptible to infection. Part of the problem is the inability of the communities to remove their waste quickly without it entering the water supply. Urban agriculture can help to address this.

Paul Calvert of EcoSolutions India, a participant of the FAO’s electronic conference on Urban and Peri-Urban Agriculture, asserts that agricultural incentives can utilise human waste as fertiliser, which keeps nutrients in the soil where they can be utilised and out of the community’s drinking water (2000). Depending on the community’s situation, urban greening may or may not be a relevant way to combat poor sanitation on its own. But combining urban agriculture with domestic hygiene (e.g. hand washing) and household cleanliness, the parasite load of the immediate environment can be lowered to a healthier level (Protecting the Human Environment, 2001). For some communities, gardens may offer an alternative to dumping their waste into the communal water supply which, even if it does not create safe drinking water on its own can allow the community to take responsibility for their impact on their environment. It can also impact on the parasite load within homes and living quarters. “To allow for transmission of infectious agents they have to be present in the immediate human environment, exposure has to take place, and transmission has to occur by uptake of the agents through unsafe practices.”(Protecting the Human Environment, 2001) The ability to dispose of domestic waste through being used as fertiliser, although may begin as an almost insignificant act of environmental sanitation, may spread to other communities, making a bigger impact on water quality in the future.

Habitat for Disease Vectors

Another important aspect of urban greening for the community is the reclamation of unused land and creating a healthier environment near one’s home. In large, quickly expanding cities where little or no urban planning has been followed, plots of land that have not been developed dot the city. For example, 39.8% of Bangkok’s urban area as of 1992 was classified as vacant (Pornchokchia, p. 31). These empty lots become dumping grounds for refuse, chemicals and/or overgrown with weeds. These pieces of unused land can become breeding grounds for vectors of disease. To illustrate this, two diseases of global concern, Dengue Fever and Malaria, will be used for illustration.

Dengue Fever (DF)

Dengue fever is a group of four viruses that are transmitted mostly by the mosquito Aedes aegypti. The mosquito larvae are laid in water that collects in pots, jars, tires, anywhere that will hold water, then spends its mature life indoors in dark places such as under beds and in closets (The Lancet, 1998). “DF is an acute febrile illness characterised by frontal headache, retro-ocular pain, muscle and joint pain, nausea, vomiting and rash” (The Lancet, 1998). The disease usually runs its course in 3-7 days, leaving the victim to recuperate, which may take some time depending on the individual’s immune system status, and with immunity to that specific strain of DF (The Lancet, 1998). However, the danger of DF lies in the possibility that it may progress to Dengue Haemorrhagic Fever (DHF) and to Dengue Shock Syndrome (DSS), both of which are life-threatening events (Lancet, 1998). Even if the victim does not develop DHF or DSS, he or she will lose days of work, perhaps weeks depending upon how healthy he or she was before the sickness, which is time many lower-income families cannot afford to lose.

As DHF epidemics have spread throughout the Americas and Asia-Pacific countries, especially in crowded, urban environments, (Horton, 1996) the possible reduction of effective breeding sites is an obvious benefit. While Urban agriculture has the potential for decreasing mosquito habitat, it can also increase it. Plants and trees with large leaves can accumulate water and hold it long enough to create a viable breeding site. As a result of this, a careful consideration of what type of trees to plant must be made as some may inadvertently create new habitats, such as the axils of banana tree leaves (Lines, 2000), tree holes and empty coconut shells (The Lancet, 1998). By reducing standing water wherever it accumulates, and planting trees and plants that will absorb water from puddles, along with diligently covering household liquid-holding containers, the community can begin to reduce the carrying capacity of the Ae. aegypti habitat.

Malaria

Malaria is another mosquito-borne parasite that has the potential to flourish in urban areas (Trigg & Kondrachine, 1998). Malaria is found mostly in tropical climates, with 90% of cases occurring in Sub-Sahara Africa (Trigg, Kondrachine, 1998). After becoming infected, there is a 10-16 day incubation period, which is followed by malaise, fatigue, vague aches and nausea (Talaro, & Talaro, 1996, p. 717) then the sufferer experiences chills, fever, and sweating, which falls into a regular pattern of resurgence every 48-72 hours, the cessation of which varies depending on the type of malaria (Talaro & Talaro, 1996, p. 717).

Anopheles mosquitoes carry malaria, with hundreds of species scattered throughout the world (Lock, Aug., 2000). According to Dr. Karen Lock, “it is important to realise that different mosquito species are responsible for spreading malaria in different regions of the world. In each locality there are usually only one or two important species, each having a unique combination of breeding site preferences and other behaviours” (Aug, 2000). If malaria is a concern to the community, effort needs to be made to discover what species is indigenous to the area, where it likes to breed and what action should be taken to curb their population. “In general,” writes Lock, “the Anopheles mosquitoes breed in water that is: relatively clean; shallow; slow flowing or still; surrounded by vegetation” (2000). This type of breeding site may discourage the planting of vegetation that needs clean still water for its survival, such as rice or sweet potatoes, or irrigation ditches that can hold water for a long time.

After a failed attempt at eradicating malaria that occurred between 1956 and 1969, WHO has directed its malaria control efforts towards promoting primary health care (Trigg & Kondrachine, 1998). The “Global Malaria Control Strategy…is rooted in the primary health care approach and calls for flexible, decentralized programmes, based on disease rather than parasite control, using the rational and selective use of tools to combat malaria” (Trigg & Kondrachine, 1998). Given that both the malaria vector and parasite have adapted to anti-malarial drugs and insecticides, and is spreading to new environments, a community approach to address this problem is more appropriate. This approach can be directed towards other diseases, such as dengue and local diseases of concern. WHO has identified four basic technical elements of primary health care (Trigg & Kondrachine, 1998):

1. to provide early diagnosis and prompt treatment;
2. to plan and implement selective and sustainable preventative measures, including vector control;
3. to detect, contain, or prevent epidemics; and
4. to strengthen local capacities in basic and applied research to permit and promote the regular assessment of a country’s [or community’s] malaria situation, in particular, the ecological, social, and economic determinants of the disease.

The community can take up the responsibility for these four elements, especially the second element when planning for urban greening projects. If the urban greening group can join forces with primary health care professionals, they can address the fourth point, tailoring the development of the project to implement research parameters needed to follow how well the urban greening initiative met the health goals proposed of the community.

Dengue Fever and Malaria are two examples of vector-born diseases that have been used as illustrations due to their global impact. Like many diseases, their epidemiology is flowing and dynamic, spreading and dissipating, depending on how optimal conditions are for that disease to flourish. It must be understood that it is not intended for this report to cover all the health implications of a proposed urban greening (or any other developmental project), but rather to give examples of possible areas that may help planners and stakeholders to begin to think about the health implications of their actions.

Health Impact Assessment

The key to this discussion is that “a healthy population is seldom found in an unhealthy environment” (Regional Consultation on the preparation of guidelines for environmental health impact assessment (EHIA) of development projects., 1994). Urban Greening offers many possibilities that will enhance the overall health of a community in conjunction with enhancing the environment. As the above examples illustrate, examining health concerns and tailoring urban greening or agricultural development to meet those concerns can address environmental and health issues at the same time. Urban Greening projects can give a community the opportunity to better feed itself, allow it to promote better sanitation or limit vector habitat while also creating a more appealing environment to live in due to the environmental benefits of green spaces. Through a larger vision of community development, the community, along with the environmental and health care professionals, can plan and implement projects, that will improve both the environment and public health at once. By improving the health of a community, especially poor communities, one improves their chances to break through the cycle of poverty.

How does one know the best way to proceed? According to the World Development Report: Investing in Health (1993) there is a need for relevant information of environmental and occupational development that defines “…a detailed, reliable assessment of the demographic conditions and the burden of disease”. (Jamison and Jardel, as quoted in Pastides, & Corvalan, 1997) The report goes on to point out “… there has been relatively little systematic, rigorous, and clearly articulated research in this field” (Pastides, & Corvalan, 1997). In other words, there are very few studies that planners and communities can use to promote their ideas and projects to funding agents. To create a project that addresses health implications through environmental development such as urban greening and record what effect it has on the community will begin to fill this gap in knowledge. Starting a project with the added goal of pursuing research on how such projects affect morbidity and mortality will not only help to meet the demand for more information on how well these projects work (giving project developers a foundation to promote future projects to governments, social services and communities), but will also allow for other organisations to be involved, creating a more holistic approach. It is more cost-efficient to have environmental, health, social, and political groups pool their resources at the time of a major developmental project than to have separate groups having to “fix the mistakes” left in the wake of one another. Global organisations such as the Food and Agriculture Organisation (FAO) and the World Health Organisation (WHO) have already come to the conclusions that the most cost-effective and efficient way to promote sustainable development is through decentralized, intersectoral, and flexible approaches that include all stake holders rather than through centralized, focused projects done by segmented specialists (FAO, 1999, Trigg and Kondrachine, 1998).

Although this approach is considered (in theory) by many to be the most proactive and sensible way to tackle developmental projects and concerns, the fact that it is still very new with little good research means that following this philosophy could be wrought with unanswered questions and false starts. However, this is a very exciting opportunity as organisations and communities that embrace this approach will be breaking new ground, forging networks and creating novel research opportunities that are sorely lacking in the present literature (Pastides, & Corvalan, 1997). To address some of the questions regarding how to begin, the World Health Organisation and the International Labour Organisation (ILO) have convened to review “the various methods which have been proposed for the quantitative assessment of how environmental and occupational exposures impact a population’s health status” (Pastides, & Corvalan, 1997), resulting in the “Methods For Health Impact Assessment in Environmental and Occupational Health”, a comprehensive look at the consultation efforts and recommendations for the promotion of evidence-based research and developmental projects in this field.

This report outlines various approaches, different types of analysis and research incentives, and case studies of Environmental and Occupational Health Impact Assessment (EOHIA) initiatives. It outlines various definitions of health impacts from mortality rate assessments, to the incidences of disease, to the more elusive “burden of disease” (Pastides, & Corvalan, 1997). Depending on what health concerns the community has, the researcher would need to select the appropriate assessment model, the time scale needed, and if the community is impacted by the loss of life, the loss of work, or the loss of human potential (Pastides, & Corvalan, 1997). These queries will sometimes require researchers to think of approaches that may not be completely quantitative; “Some environment-health relationships are intrinsically difficult or impossible to quantify and yet health impacts maybe [sic] substantial” (Pastides, & Corvalan, 1997). As explored above, the elimination of night blindness due to increased vitamin A intake as a result of access to fresh fruits and vegetables in a new community garden is an easy, quantifiable research end, but the increased intelligence levels of a community as children grow up with less intestinal parasites and higher nutrient absorption due to sanitation efforts is less so. Does it make it any less important to pursue? Of course not. Some of the health concerns that face poor communities will take years to rectify and the EOHIA attempts to take this into account.

Nurses’ Role In Development

Throughout this report, “health care professionals” has been used to encompass nurses, doctors, medical researchers and other professionals in the health care field. Let us now focus on the role of nursing, the largest and most diverse group among these professionals. In a key note address to the International Council of Nurses Centennial Conference, Dr. Gro Harlem Brundtland, General-Director of WHO left no doubt as to where nurses fit within the health care team.

In setting the future directions for global health policy, nursing and midwifery are key elements. As nurses and midwives already constitute up to 80% of the qualified health workforce in most national health systems, they represent a potentially powerful force for bringing about the necessary changes to meet the needs of Health for All in the 21st century. Indeed, their contribution to health services covers the whole spectrum of health care, promotion and prevention, as well as health research, planning, implementation and innovation. (1999)

The wealth of skills and knowledge of the biological and sociological basis of health can be joined to the environmental expertise of the Urban Greening project and the desires and concerns of the community, creating a more holistic team. This diverse group will be able to troubleshoot conflicts, as overlapping and complex environmental factors may be contraindicative of certain health concerns and these need to be addressed. For example, high toxin levels in soil, or the use of plants as sinks for waste material may contraindicate planting fruit and vegetables that may absorb these toxins and be ingested by people or livestock. Would the micronutrient benefits outweigh the possible toxin ingestion? Which plants uptake which toxins and at what rate? Could plants that have efficient absorbing qualities be used to de-toxify an area and then plant vegetables? Depending on the answers to these questions, the community may be free to plant edible plants, or create a multi-step project with the end result being a vegetable garden, or decide that another project is more appropriate. But these questions may not be asked or pursued if urban greening projects are implemented in isolation from health care professionals, such as the community nurses. Also, as the community nurse will stay within the community, she or he will be in the position to follow the progress of the project, promote formal and informal education sessions, assess the health of the people and record any positive or negative data that may come out of it with tools such as the EOHIA.

Conclusion

We have seen astounding changes in the last fifty years, some of which we still have not grasped their entire impact. As we begin to take stock of the repercussions of our progress, it becomes apparent that the very advances in technology and urbanization are also creating ill health in those who live in poverty. The pollution, lack of proper nutrition, poor water and environmental sanitation, communicable and non-communicable diseases are all pressing in on the communities who are least able to fight back. As Dr. Gro Harlem Brundtland states “90% of the disease burden is in the developing countries, these countries have access to only 10% of the resources going to health” (1999) indicating that any health promoting acts in the poor communities of the world will fill a void in their health care. The links between the environment and public health are becoming more evident and efforts are being made to address both concerns at once. Although the benefits of Urban Greening are usually explored in an environmental context, there is now an opportunity for planners, health care professionals and communities, along with governments, policy officials and funding agencies, to share their expertise to create a holistic, cost-effective program, with greater understanding of the links between our world and our health.

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