Environmental risks contributed 24% (95% CI = 21–27%) to the global burden of disease measured in DALYs and by 23% (21–25%) to all deaths. The diseases with the largest environmental contributions globally are displayed in Figure 2 for the year 2002. Together, the 5 diseases with the largest contributions—diarrhea, lower respiratory infections, other unintentional injuries, malaria, and road traffic injuries—were responsible for more than 10% of the global burden of disease (in DALYs). The environmental attributable fractions varied widely across regions (Fig. 3). Children carried a disproportionate share of the disease burden; in children 0 to 14 years old, environmental attributable fractions of all deaths were as high as 36% (31–40%).
Diarrheal diseases, lower respiratory infections, neuropsychiatric conditions, and cardiovascular diseases are the largest contributors to global disease with an environmental component. These diseases together accounted for more than one third of the disease burden from environmental risks. Diarrheal diseases and lower respiratory infections mostly affected children in developing countries, whereas neuropsychiatric disorders and cardiovascular diseases mainly affected adults in both developed and developing countries.
The WHO report provides a systematic and comprehensive estimate of how much of the global burden of disease can be prevented by environmental management. Only the reasonably modifiable environment was taken into account; therefore, the joint evidence from interventions studies and expert estimates indicate the potential burden of disease that could reasonably be prevented by environmental interventions. The study represents a comprehensive estimate, because all major diseases and environmental risk factors were included. It adds to previous compilations of evidence2–6 and presents results in terms of mortality and a common metric (DALYs).
A limitation of the study is the lack of the type of evidence that is available from other areas of public health such as treatment of disease. This lack leads to larger uncertainties, and the evidence may be improved as new studies emerge. Nevertheless, this is the best available evidence and provides decision-makers with indicative information as to where environmental modification has the greatest potential to alleviate the burden of disease.
The study purposefully erred to be conservative in estimating the environmental contribution to global burden of disease. The scientific literature, the main basis for expert opinion, was poor for many diseases or risks, and experts were therefore not able to consider the full links between environment and disease. This lack of evidence for some environmental risks include contaminants in our air, water, and food, and other risks in our environment, which often have complex linkages with disease that cannot be measured with current risk assessment tools for populations. The results can, however, be used to identify the research gaps for many diseases, risk factors, and integrated approaches.
The study does not address the cost or cost-effectiveness of interventions, which will be addressed in a later report.
Within these limitations, the compilation of the evidence of environmental contributions to all diseases presents us with the following implications.
The evidence that modifiable environmental factors contribute to 85 of 102 diseases, and account for 24% of the global disease burden, represents an important increase compared with previous systematically collected evidence (eg, 10% as estimated by the Comparative Risk Assessment) and highlights the great potential of environmental action for improving public health. This potential is likely understated because the methods applied in this study are likely to have led to conservative estimates of the environmental disease burden.
Currently, people in developing countries lose many more healthy life years to environmental causes than do people in developed countries. For infectious diseases, the per capita loss of healthy life years from environmental risks is 15 times higher in developing countries and approximately twice as high for unintentional injuries. Overall, there was no difference in the disease burden between developed and developing countries for noncommunicable diseases, although per capita rates for cancers and cardiovascular diseases were approximately twice as high in developed countries.
Children experience a disproportionate share of the environmental disease burden with the per capita rate for DALYs lost in children under 5 years being 5 times that in the total population. Diarrheal diseases, lower respiratory infections, malaria, and malnutrition (including the impact of malnutrition on infectious diseases) all have a large environmental component and disproportionately impact on children.
Environmental health actions generally produce longer-term impacts that go beyond the health sector. Providing safe water and adequate sanitation, for example, can return 7 times the initial investment.156 Similarly, a switch to cleaner fuels can produce returns of 3 times the investment over a 10-year period.157
Environmental interventions contribute to goal 1: to eradicate extreme poverty and hunger, because many environmental risks disproportionately affect poorer populations. Environmentally caused disease can also reduce earnings, which in turn reinforces the cycle of poverty and hunger. Environmental action to relieve the burden of disease would thus help to break the poverty. The 60-fold difference in per capita malnutrition rates between the highest and lowest region underline the potential to combat these inequalities with environmental action. Environmental action to reduce the disease burden would contribute to goal 2: to achieve universal primary education, because healthy children have more time to spend on education. Children spending less time collecting solid fuels or drinking water would also have more time for education. Installing adequate latrines at schools would improve the attendance of girls. The contributions of environmental modification to goal 3—to promote gender equality and empower women—are similar to those for goal 2, because women, like children, often spend time collecting drinking water or solid fuels. Environmental action to provide drinking water, for example, would free the women to generate income and improve the nutritional status of the family, because women are generally the main caregivers for household members.
Diarrheal diseases, lower respiratory infections, and malaria all have large environmental components with attributable fractions of 94%, 42%, and 41%, respectively, and all are big child killers. Interventions against these diseases would thus contribute to goal 4: to reduce the child mortality rate.
Environmental interventions to provide safe and sustainable sources of water and clean energy supplies could reduce the number of deaths from diarrhea and lower respiratory infections by 2 million per year. Environmental-related transmission of disease results in half a million deaths annually from malaria and to one fourth of a million deaths from HIV/AIDS. Environmental action thus makes significant and even necessary contributions to achieving goal 6: to combat HIV/AIDS, malaria, and other diseases. Key environmental interventions for goal 6 such as providing clean household fuels, safe water, and sanitation greatly contribute to goal 7: to ensure a sustainable environment. Environmental health action thus has the potential to make a significant contribution toward achieving the Millennium Development Goals and may even be essential for success.
In summary, we believe that this study presents a useful analytic framework for collecting and presenting scientific evidence that is of direct relevance to policymakers and other stakeholders both in measuring the overall impact of environmental risk factors on human health and in highlighting specific areas in which environmental interventions should bring about the greatest human health gains. Applying this approach, and incorporating the best available evidence, suggests that creating healthier environments can prevent approximately one fourth of the disease burden globally in a way that is sustainable, improves equity, and brings multiple benefits. It therefore supports the case that interventions for healthy environments should be an important component of any strategy to improve global public health.
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