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Environmental Issues in Health:

Clean Air and Water


CFM I: Family and Preventive Medicine

Louricha A. Opina-Tan, MD, FPAFP


Community and Family Medicine

Objectives
1. Define environmental health.
2. Appreciate environmental condition as a
social determinant of health.
2. Discuss outdoor and indoor air quality
3. Discuss global effects of air pollution
4. Discuss different types of water system
5. Describe a safe drinking water
6. Discuss strategies for meeting standards

Environmental Health
addresses all the physical, chemical, and
biological factors external to a person, and all the
related factors impacting behaviours
encompasses the assessment and control of
those environmental factors that can potentially
affect health
targeted towards preventing disease and creating
health-supportive environments.

World Health Organization

Environmental Health
concerned with preventing illness through
managing the environment and by changing
people's behavior to reduce exposure to
biological and non-biological agents of disease
and injury
concerned primarily with effects of the
environment to the health of the people.
Department of Health, Philippines

- year 2004
- 24 global risk factors

Health Risk
A factor that raises the probability of adverse
health outcomes
Measured thru:
Mortality
Disease Adjusted Life Years

World Health Organization, 2009

Criteria for choice of Risk Factor


A potential for global impact
A high likelihood that the risk causes each
associated disease
A potential for modification
Being neither too broad not too specific
Reasonable complete data were available for
that risk
World Health Organization, 2009

Environmental Risks

Global climate change


Urban outdoor air pollution
Lead exposure
Indoor smoke from solid fuels
Unsafe water, sanitation and hygiene

nearly 10% of
deaths and disease
burden globally
around 25% of
deaths and disease
burden in children
under 5 years old

Video

AIR POLLUTION:
Indoor and Outdoor

Air pollution
Contamination of the indoor and outdoor
environment by any chemical, physical or
biological agent that modifies the natural
characteristics of the atmosphere.

Outdoor or Indoor

Air Pollution
More than 2M premature deaths each year
can be attributed to the effects of urban
outdoor air pollution and indoor air pollution
More than half of this disease burden is borne by
the populations of developing countries

Outdoor (Ambient) Air Pollution

Ozone (Ground-level)
Particulate matter
Carbon monoxide
Nitrogen oxides
Sulfur dioxide
Lead
ES Environmental Protection Agency

Pollutant

Source

OZONE (O3)

Chemical reaction between oxides of


Nitrogen and volatile organic compounds
Industrial facilities and electric utilities,
motor vehicle exhaust, gasoline vapors
and chemical solvent

Particulate
Matter

Complex mixture of very small particles


and liquid droplets (acids, organic
chemicals, metals and soil or dust
particles)

Effects
Children are at highest risk
Sensitive vegetation
especially during growing
season
Reduced visibility
Lung problems

10u or less because they can enter


lungs**

Carbon
monoxide

Colorless, odorless gas emitted from


combustion processes (vehicles)

Reduce the oxygen-carrying


capacity of the blood

Pollutant

Source

Nitrogen From emissions from cars, trucks,


buses power plans and off-road
Oxides
equipments

Effects
Airway inflammation and
increased respiratory
symptoms in people with
asthma

Contributes to ground-level ozone


and particulate matter

Sulfur
dioxide

Fossil fuel combustion at power


plants and industrial facilities

Bronchoconstriction and
increased asthma
symptoms

Lead

Fuels in on-road motor vehicle


gasoline

Absorbed and accumulates


in the bone, affects the
nervous system, kidney
function, immune system,
developmental systems and
cardiovascular system

Lead smelters, ore and metals


processing and piston-engine
aircraft operating on leaded
aviation gasoline

Affects oxygen-carrying
capacity of blood

HAP video 1

Indoor (Household) Air Pollution


Global Burden of disease
Exposure to HAP
Results to around 4M premature deaths
Nearly 5% of the global disease burden

Single most important environmental risk


factor

Household Air Pollution


Caused by household energy practices
Use of solid fuels and simple stoves for cooking
Use of kerosene lamps
Aggravated by poorly ventilated dwellilngs

Contributes to ambient air-pollution

High risk for burns, poisoning and injuries


Limits productivity
Takes children away from school

HAP video 2

Household Air Pollution


Interventions to control
1. Changing the source of pollution
Improved cooking devices: biomass stove w/o fuel
Alternative fuel-cooker combinations: LPG,
electric
Reduced need for fire: solar water heating

Household Air Pollution


Interventions to control
2. Improving the living environment
Improved ventilation: smoke hood
Kitchen design and placement of the stove:
separate kitchen

Household Air Pollution


Interventions to control
3. Modifying user behavior
Reduced exposure by changing cooking practices:
use of pot lids, food preparation to reduce time
Reduction by avoiding smoke: keep children away
from smoke

Safe Water

Water in Earth
Only 2.5% of water available on Earth is
freshwater, but a significant portion of this is
inaccessible
Rivers, lakes, underground
Investments in safe drinking water and
improved sanitation show a close
correspondence with improvement in human
health and economic productivity

Water Sources
Rainwater
Surface water rivers, lakes, streams, ponds,
impounding reservoir, seas and oceans
Groundwater spring, well, infiltration
galleries / wells

Threats to Water
Land use
Deforestation
Climate change
Increased consumption due to growing
populations
Pollution

Water Pollution
Any contamination of water with chemicals or
other foreign substances that are detrimental
to human, plant or animal health

Importance of Water Safety


Unsafe water and inadequate sanitation and
hygiene are significant contributors to the
1.8M deaths caused by diarrhea every year
Water transmits diseases

Water-related diseases
Water-borne
Ingested in drinking water

Water-washed
Associated with inadequate supplies of water for
proper personal hygiene

Water-based
Transmitted through an invertebrate host or
water-related vector

Interventions for
Water-related Diseases
Water-borne
Improvement in sanitation, personal and
microbiological water quality

Water-washed
Improvement in water supplies

Water-based
Improvement in water supplies

Water safety = Water quality

Water video

Water Quality
Biological
Bacteria, viruses, protozoa, worms

Chemical
Minerals, metals and other chemicals

Physical
Temperature, color, smell, taste, turbidity

Biological
Bacteria, viruses and protozoa
Major threat from these is diarrhea
Infective dose
Minimum number of pathogens needed to cause
illness in a person

Indicator organisms
Presence of absence of certain bacteria is used to
determine safety of water
Coliform bacteria is most common indicator (E coli)

Chemical
Usually causes concern only after chronic
exposure
Sources
Naturally found (arsenic, calcium, flouride,
magnesium, sulfur)
Human activities: agriculture and industry
(nitrogen, phosphorus and pesticides)

Chemical
Health effects
Arsenic - arsenicosis
Flouride damage teeth, crippling skeletal damage
Nitrates and nitrites blue baby syndrome of
methemoglobinemia

Other
Iron nuisance : color and taste
Manganese nuisance: color and taste and stain

Total dissolved solids


Inorganic salts (NaCl, Ca, Mg, K) : hard or soft
Soap is less effective, can leave residue, flat or bitter
or salty taste

Physical
Aesthetic characteristics
Turbidity, color, taste, smell and temperature

Drinking water
Generally clear, tastes good, has no smell and is
cool

Standard values for physical and


chemical qualities for acceptability
(Philippine National Standards for
Drinking Water, 2007)

Constituent Maximum level or


Characteristic
Taste
Odor
Color
pH

Turbidity
Aluminum
Chloride
hardness
Hydrogen sulfide

No objectionable taste
No objectionable odor
True: 5 NTU, Apparent: 10
NTU
6.5 to 8.5
5 NTU
0.2 mg/L
250 mg/L
300 as CaCO3
0.05 mg/L

Constituent Maximum level or


Characteristic
Iron
Manganese
Sodium
Sulfate
Total Dissolved
Solids
zinc

1.0 mg/L
0.4 mg/L
200 mg/L
250 mg/L
500
5

Millennium Development Goal


To reduce by half the proportion of people
without sustainable access to safe drinking
water

Water Safety
Ideal:

Provide safe, reliable, piped-in water to every


household

WATER DISTRIBUTION SYSTEM


Designed to adequately satisfy the water
requirements for a combinations of the
following demands:
Domestic
Commercial
Industrial
Fire-fighting

Can satisfactorily meet the demands at all


times

Water Service Levels


Describes the method by which the water is
made available to the consumers

Water Service Levels


Level I (Point Source)
Provides a protected well or a developed spring
with an outlet but without a distribution system
Usually serves an average of 15 households within
a radius of 250 meters.

Water Service Levels


Level II (Communal Faucet System or Stand
Posts)
Composed of a source, a reservoir, a piped
distribution network and communal faucets
One faucet serves 4 to 6 households within a
radius of 25 meters.

Water Service Levels


Level III (Waterworks System or Individual
House Connection)
Includes a source, a reservoir, a piped distribution
network and individual household taps

Number of Households by Main Source of Water Supply,


Philippines as of year 2000, National Statistics Office
Source of Water Supply

Number of
Households

% of Total

Own Use Faucet, Community Water


System

4 177 722

27.3

Shared Faucet, Community Water System 2 950 891

19.3

Own Use Tubed/Piped Deep Well

1389 768

9.1

Shared Tubed/Piped Deep Well

2 406 228

15.7

Tubed/Piped Shallow Well

1 098 552

7.2

Dug Well

1 209 319

7.9

Spring, Lake, River, etc

1 350 735

8.8

Peddler

348 636

2.3

Bottled Water

55 226

0.4

Others

291 731

1.9

TOTAL

15 278 808

100

Water and Sanitation in the Philippines


Access to safe water supply* declined from
87% (1990) to 85% (2004)
*defined as access to potable water regardless
of whether piped systems or lower level
UNICEF and WHO, 2004

Water and Sanitation in the Philippines


Up to 58 % of groundwater is contaminated
with coliform
Many areas are experiencing a shortage of
water supply during the dry season

Water Safety
In the interim:

Safe water approaches in households

Household Water Treatment and


Safe Storage (HWTS)
Treating water and safely storing it in the
home
Treating water at the point of use
Multi-barrier approach

Household Water Treatment and


Safe Storage (HWTS)
Rationale:
In many settings, both urban and rural,
populations have access to sufficient
quantities of water, but that water is unsafe
for consumption as a result of microbial or
chemical contamination

Household Water Treatment and


Safe Storage (HWTS)
Rationale:
For piped-in water, recontamination can
happen leading to microbial infiltration of
poorly maintained systems

Household Water Treatment and


Safe Storage (HWTS)
Rationale:
Household level can remove, kill or inactivate
most microbial pathogens
minimizes risk of recontamination since
focused at the point of use rather than point
of delivery

Household Water Treatment and


Safe Storage (HWTS)
Rationale:
Works in both development and emergency
situations to reduce the number of diarrheal
cases

Household Water Treatment and


Safe Storage (HWTS)
Challenges
establishing microbiological performance

achieving coverage and uptake

Methods of Household Water


Treatment
Water source protection
Use the best possible source of water

Poor site selection


Poor protection of the water source against pollution
Poor structure design or construction
Deterioration or damage to structures
Lack of hygiene and sanitation knowledge and
practice in the community

Water source protection


Regularly clean the area around the water source
Move latrines away from and downstream of water
sources
Build fences to prevent animals from getting into open
water sources
Line wells to prevent surface water from contaminating
groundwater
Build proper drainage for wastewater around taps and
wells
Stabilize springs against erosion and protection from
surface run-off contamination
Ensure watershed use is non-polluting

Methods of Household Water


Treatment
Sedimentation
To reduce turbidity of water
Letting the water to settle for some time
Can be accelerated by adding coagulants
Alum (aluminum sulfate, aluminum chloride, iron salts
Native plants moringa seeds

Methods of Household Water


Treatment
Filtration
To reduce turbidity of water and remove
pathogens
Involves passing water through filter media (some
may have biological layer that kills pathogens)
Biosand filters, ceramic candle/pot filters,
membrane filters, activated carbon

Methods of Household Water


Treatment
Disinfection
To kill or inactivate pathogens
Chlorine disinfection
Solar disinfection
Ultraviolet disinfection
boiling

Methods of Household Water


Treatment
Distillation
Use suns energy to treat drinking-water
Evaporating water into vapour, then capturing and
cooling the vapor so it condenses back into a
liquid

Safe Water Storage


Have a strong and tightly sealing lid or cover
Have a tap or narrow opening at the outlet for
access
Have a stable base so it does not tip over
Be durable and strong
Be easy to clean

Other safe water handling practices


Using a container for collecting and storing only
untreated water
Using a separate container for storing only treated
water
Regularly cleaning the storage container with soap
Storing treated water off the ground
Storing treated water away from animals
Pouring treated water from the container instead of
scooping the water out of it
Using the water as soon as possible after it is treated,
preferably on the same day

Limitations of HWTS
Mainly to improve water quality
Not alternative to reliable, well-managed and safe
piped-in water supplies
Should not divert resources away from long-term
government efforts

Limitations of HWTS
Mainly improves microbiological water quality
and some do not remove all types of
pathogens
protozoa cysts (Cryptosporidium) are resistant to
chlorine
Filters are not effective in removing viruses

Limitations of HWTS
It must be used correctly, consistently and
exclusively, especially among vulnerable
groups
Ensure uptake and solutions must be accessible,
affordable, acceptable and sustained

National Policies Relevant to


Air and Water Pollution
Clean Air Act
Clean Water Act

Philippine Clean Air Act of 1999


(RA 8749)
comprehensive air quality management policy
and program which aims to achieve and
maintain healthy air for all Filipinos

Philippine Clean Air Act


(RA 8749)
sets emission standards for all motor vehicles
and issues registration only upon
demonstration of compliance
issues pollutant limitations for industry
polluting vehicles and industrial processes
must pay a charge
installing pollution control devices can lead to
tax rebates, etc

Philippine Clean Air Act


(RA 8749)
establishes a research and development
program for air pollution reduction
mechanisms and technologies
bans incineration and smoking in public
places*
governments are allowed to set emission
quotas by pollution source
development of recycling programs is
encouraged

Philippine Clean Water Act of 2004


(RA 9275)
providing for a comprehensive water quality
management and for other purposes

Philippine Clean Water Act of 2004


(RA 9275)
Water Quality Management Area Action Plan
Domestic Sewage Collection, Treatment and
Disposal

Philippine Clean Water Act of 2004


(RA 9275)
Prohibited Acts
a) Discharging, depositing or causing to be
deposited material of any kind directly or
indirectly into the water bodies
b) Discharging, injecting or allowing to seep
into the soil or sub-soil any substance in any
form that would pollute groundwater.
c) Operating facilities that discharge regulated
water pollutants without the valid required
permits

Philippine Clean Water Act of 2004


(RA 9275)
Prohibited Acts
d) Disposal of potentially infectious medical waste into sea
water
e) Unauthorized transport or dumping into sea waters of
sewage sludge or solid waste as defined under Republic Act
No.9003;
f) Transport, dumping or discharge of prohibited chemicals,
substances or pollutants listed under Republic Act No.6969;
g) Operate facilities that discharge or allow to seep, willfully
or through gross negligence, prohibited chemicals,
substances
h) Undertaking activities or development and expansion of
projects, or operating wastewater/sewerage facilities in
violation of Presidential Decree. No.1586

Philippine Clean Water Act of 2004


(RA 9275)
Prohibited Acts
d) Disposal of potentially infectious medical
waste into sea water
e) Unauthorized transport or dumping into
sea waters of sewage sludge or solid waste as
defined under Republic Act No.9003;

Philippine Clean Water Act of 2004


(RA 9275)
Prohibited Acts
f) Transport, dumping or discharge of prohibited
chemicals, substances or pollutants listed under
Republic Act No.6969;
g) Operate facilities that discharge or allow to
seep, willfully or through gross negligence,
prohibited chemicals, substances
h) Undertaking activities or development and
expansion of projects, or operating
wastewater/sewerage facilities in violation of
Presidential Decree. No.1586

Philippine Clean Water Act of 2004


(RA 9275)
Prohibited Acts
i) Discharging regulated water pollutants
without the valid required discharge permit
j) Non-compliance of the LGU with the Water
Quality Framework and Management Area
Action Plan
k) Refusal to allow entry, inspection and
monitoring by the Department in accordance
with this Act;

Philippine Clean Water Act of 2004


(RA 9275)
Prohibited Acts
l) Refusal to allow access by the Department to
relevant reports and records in accordance with this
Act;
m) Refusal or failure to submit reports whenever
required by the Department in accordance with this
Act;
n) Refusal or failure to designate pollution control
officers whenever required by, the Department in
accordance with this Act; and
o) Directly using booster pumps in the distribution
system or tampering with the water supply in such a
way as to alter or impair the water quality.

Maraming Salamat!

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