WHO NEWS
How bad is the environment for our health?
Since Kerstin Leitner became Assistant Director-General of WHO's Sustainable Development and Healthy Environment cluster of departments, in September 2003, her team have sharpened their focus to provide information and knowledge to numerous Member States on the public health impact of environmental factors. She talks about this and other aspects of her cluster's work.
Q: What is the disease burden due to environmental factors?
A: Some experts say a third of the disease burden of children is due to environmental factors. It's extremely difficult to prove that. We often lack the epidemiological basis. Often we only have 'guestimates'. We know that allergies and asthma are caused by environmental factors, but it's difficult to say to what extent and whether people become susceptible to allergies because of air pollution or chemical residues in food. There is clearly a link between certain types of cancer and environmental factors. One of the best known cases is asbestos and lung cancer. But lung cancer can also be caused by other factors, such as smoking. This is where our work is particularly demanding. You have to make judgements. You don't want to be alarmist but also not too laid back. You need to strike a balance.
Q: Have you changed your team's focus in any way?
A: We have become sharper in our focus as we look at environmental, social and economic determinants of health and globalization. We always put the emphasis on the public health dimension. It's easy to get carried away by various aspects of chemical safety, but our task is to look at the impact of this on individual and public health and what public health authorities in particular ministries of health should be doing to protect people's health. It sounds easy but often it is not. We work in a context where we do not have full scientific or epidemiological information, so there has to be a consultation process between us and the scientists, and then with our clients, the ministries of health, and with other stakeholders. We need to decide whether WHO should recommend precautionary measures, for example, when we are dealing with health threats that can cause irreversible damage.
Q: Does your work bring WHO into conflict with industry?
A: Over the last few years more and more big companies see that it is in their long-term interest to have a safety, health and environmental policy which they can apply to themselves as well as to their suppliers and distributors. Occasionally you hit on an issue where you cannot identify a real viable alternative for industry. That is when things can get rough. We have seen this in the past with the tobacco industry, now the sugar industry and, in our field of interest, it's the asbestos mining industry.
Q: Why is a sector-wide approach to health needed and how does this work?
A: If a developing country is donor attractive, the last thing you want is to have national government funding for these sectors running in parallel to that of donors. A sector-wide approach allows the government to state where it would like to invest itself and where it would welcome donor support. In its current incarnation the sector-wide approach is fairly new, but there have been precursors. WHO has also developed a guidance note on how the UN system could and should participate in sector-wide approaches.
Q: What progress has your cluster made in terms of supporting Member States through the Country Focus Office?
A: As a pilot project, we started by assessing what it would take to re-profile the country offices of Kenya, Malawi and the United Republic of Tanzania to be responsive to the needs of each country's health sector. Africa is the region that has most actively embraced this approach. These countries have formed at least one country cooperation strategy and are in the process of replicating the experience in Kenya to re-profile all their country offices.
Q: Why are you handling this? Isn't this an administrative task?
A: No. There is clearly an administrative and managerial task involved, but we are looking at a sophisticated assessment of technical needs. For example, just because you have a major DOTS programme does not mean you need a tuberculosis expert in that office. If a country has institutions capable of delivering a DOTS programme for tuberculosis effectively you don't need to spend money on a DOTS expert. You may be better off providing a multidisciplinary team to monitor progress of that national programme.
Q: What are you doing to help countries with inadequate health legislation?
A: We are in the process of formulating model legislation which countries can adapt to help them achieve the Millennium Development Goals. Many countries revise public health legislation and many never do. There are some former colonies whose health legislation probably dates back to colonial times. It doesn't mean this is obsolete, most likely not, but sometimes it needs to be brought up to date. Furthermore, we have collected existing legislation from many countries, so we can provide Member States with examples of existing laws.
Q: What simple, cost-effective interventions could make environments substantially healthier and food much safer?
A: There's one and it's something that often gets short shrift when there is an outbreak of infectious disease and that's hygiene. Hygiene can carry us a long way. Hygiene is written into the WHO constitution. We have developed the Five Keys to Safer Food, consisting of five very simple principles of hygiene. I don't know if it takes care of 30% or 50% of health-related problems, but it's a big step and something that can be done easily.
Q: What are you doing to improve hygiene standards?
A: Probably not enough. With regard to avian flu, in particular on small farms, there could be room for us under the heading of occupational health to develop guidance on hygiene standards and methods to handle poultry. We have been much more focused on the virus that causes it, and this is important work, but most people who died were at these small farms.
Q: When people are faced with a daily struggle for survival are ethics a luxury they can ill afford?
A: In public health, ethics are particularly important when you work under constraints. We developed a set of ethical guidelines for the '3 by 5' campaign, to get HIV/AIDS treatment to one in two poor people who need it. For example, a doctor or a nurse in a rural clinic has one HIV/AIDS treatment left. In comes a poor farmer and in comes the local teacher. Whom do you treat? Without ethical guidance medical personnel are exposed to the pulls and pushes of the situation. The teacher may be more important to the community but may get treatment by other means. If the farmer dies, a whole family will be thrown into destitution. We have also discussed the ethical dimensions of organ and tissue transplant over the last two years as well as transplantation tourism. Ethics are not a luxury, it's quite the opposite. It's in situations where you have very limited choices that you need to know how to make the right decision. 