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Linkage Methods for Environment and Health Analysis Linkage Methods for Environment and Health Analysis General guidelines A report of the Health and Environment Analysis for Decision-making (HEADLAMP) project Linkage Methods for Environment and Health Analysis General guidelines A report of the Health and Environment Analysis for Decision-making (HEADLAMP) project United Nations Environment Programme ."","".r.~", ft· {~l ,,~'7 United States Environmental Protection Agency World Health Organization Office of Global and Integrated Environmental Health World Health Organization Geneva, 1996 This document is not issued to the general public, and all rights are reserved by the World Health Organization (WHO). The document may not be reviewed, abstracted, quoted, reproduced or translated, in part or in whole, without the prior written permission of WHO. No part of this document may be stored in a retrieval system or transmitted in any form or by any means - electronic, mechanical or other - without the prior written permission of WHO. The views expressed in documents by named authors are solely the respomibility of those authors. Cover photo: WHOfNASA Contents Page Preface .............................................. vii 1. Health and Environment Analysis for Decision-making C. Corvaldn & T. Kjellstrom .......................... 2. Development of Environmental Health Indicators C. Corvaldn, D. Briggs & T. Kjellstrom .................. 19 3. Exposure Assessment T. Nurminen, M. Nurminen, C. Corvaldn & D. Briggs . ........ 55 4. Assessment of Health Effects T. Nurminen, M. Nurminen, C. Corvaldn & D. Briggs . ........ 69 5. Approaches to Linkage Analysis: Overview M. Nurminen & D. Briggs ............. ,.............. 93 6. Decision-making in Environmental Health E. Schwartz & C. Corvaldn .......................... 121 v Preface The Health and Environment Analysis for Decision-making (HEADLAMP) project is a joint collaborative project between the United Nations Environment Programme (UNEP), the United States Environmental Protection Agency (USEPA) and the World Health Organization (WHO). HEADLAMP aims to make valid and useful information on the local and national health impacts of environmental hazards available to decision-makers, environmental health professionals and local communities. It uses methodologies in environmental epidemiology, human exposure assessment and other health and environment sciences to collect and analyse data to produce information that can be understood easily and used as a basis for action. The project was initiated in late 1993 with a feasibility study to identify and adapt methods that could be used at the local level in combination with routinely collected health and environment data, to estimate the health impacts of environmental contamination. ' Field studies were later carried out in Accra (Ghana) and Sao Paulo (Brazil) to examine data availability and quality as well as the potential for linking health and environment data. One of the project's important milestones was a consultation with international experts, held in Geneva in August 1994. Several of the papers presented during that consultation were published in a special issue of the World Health Statistics Quarterly (48;1995), under the title, "Health and environment analysis and indicators for decision-making". Additionally, a report entitled Epidemiologic Methods for linking Health and Environment Data for Decision-making was reviewed, and the future direction of the project determined. , This book is a revised version of part one of that report, and deals with general issues of data linkage. Part two deals in more detail with the analytic methods. During 1995, seven field studies were conducted in Calcutta (India), Cape Town (South Africa), Cotonou (Benin), Dar es Salaam (Tanzania), Managua (Nicaragua), Manila (the Philippines), and Talcahuano (Chile). The studies focused on the development and testing of environmental health indicators, and their links to local decision-making. Preliminary findings were reviewed at a field studies meeting held in Nairobi, Kenya in October 1995. A book on the fmdings of the field studies is being planned, following the recommendations of the meeting. Instructional materials and workshops on HEADLAMP methods, and the identification, collection and use of environmental health indicators, are also being planned as part of future capacity-building activities. Vll We gratefully acknowledge the valuable comments of the many reviewers of this book who included members of a review team established at the first HEADLAMP consultation and composed of M. Akerman, U. Blumenthal, H. Pastides, P. Queuel, M. Salinas and J. Songsore. Valuable comments were also provided by M. Conomos, A. Dahl, C. Dora, T. Fletcher, G. Goldstein, H.N.B. Gopalan, K. Katsouyanni, M. Krzyzanowski, J. Leigh, A.J. McMichael, S. Markowitz, B. Nussbaum, C. Stephens, and J. Stober. Thanks are also due to J. Johnson for preparing the layout of this document. Carlos Corvahin, HEADLAMP coordinator, Office of Global and Integrated Environmental Health World Health Organization, Geneva, March 1996 Vlll 1 Health and Environment Analysis for Decision-making C. Corvaltin a & T. Kjelistrom a 1. INTRODUCTION The Health and Environment Analysis for Decision-making (HEADLAMP) project is aimed at improving information support for environmental health policies. HEADLAMP makes valid and useful information on the local and national health impacts of environmental hazards available to decision-makers, environmental health professionals and the community. It combines methodologies in environmental epidemiology, human exposure assessment and other health and environment sciences to produce and analyse data, to convert these data into information, and to present this information so that it can be understood, interpreted and acted upon by those responsible for environmental health protection. The information created via local and national HEADLAMP applications will help monitor progress towards sustainable development as recommended in Agenda 21 (UN, 1993). Important elements of HEADLAMP are methods for linkage of health and environment data, the use of environmental health indicators used to quantify and monitor the local situation, and the interpretation and translation of resulting information into the decision-making process. This chapter gives an overview of the HEADLAMP project and its background. A series of papers, published in the World Health Statistics Quarterly (Volume 48(2), 1995), present further details on HEADLAMP methods and examples of field studies, based on materials discussed at the first expert meeting on HEADLAMP held in Geneva in August-September 1994. 2. THE HEALTH AND ENVIRONMENT SITUATION Human exposure to pollutants in the air, water, soil and food - whether in the form of short-term, high level episodes, or longer-term low level exposures - is a major contributor to increased morbidity and mortality. The disease burden attributable to these exposures is not known with any degree of certainty, however, because levels of general environmental pollution fluctuate greatly, 'Office of Global and Integrated Environmental Health, World Health Organization, Geneva HEADLAMP - GENERAL GUIDELINES methods for analysing the relationships are incompletely developed, and the quality of available data is generally poor. Precise measures of the association between pollution levels and health outcomes are therefore rare. Exposure to environmental pollution is also usually involuntary and people may be ignorant of their exposure or its possible effects; as a result they may exert little control over exposure risks. Biological and chemical agents in the environment are nevertheless responsible for the premature death of millions of people and to the disablement of hundreds of millions more every year (WHO, 1992a). Certain environmental hazards affect very large populations. In large cities, for example, millions of people may be exposed to severe outdoor air pollution. In addition, indoor air pollution is a widespread and serious problem particularly in developing countries. World-wide, at least a hundred million people are potentially affected by respiratory diseases associated with air pollution (WHO, 1992a). The need to control harmful exposures is therefore evident. The ability to link health and environmental data, and thereby to understand relationships between levels of exposure and health outcome, is clearly vital in attempts to control exposures and protect health. This capability is particUlarly important for countries in which issues of environmental pollution have traditionally taken second place to demands for economic development. In many of these countries, environmental pollution is rising while populations are undergoing rapid expansion, particularly in urban centres. Levels of exposure and their potential health effects are therefore liable to increase. At the same time, awareness is growing of the links between economic growth and environmental protection, and of the need to develop strategies for sustainable development which both preserve the environment and enhance quality of life. In this context, decision-makers urgently need information on the health impacts attributable to environmental pollution in order to assess the implications of their decisions, compare the potential effects of different decisions and choices, and prevent irreversible and costly health and environmental damage. Standards and guidelines against which to assess levels of environmental pollution are now widely
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