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Health and the Environment: Integrating health concerns in National Sustainable Development


Dr Alex Andjaparidze

World Health Organisation (WHO) Representative, East Timor


"Human beings are at the centre of concerns for sustainable development. They are entitled to a healthy and productive life in harmony with nature." - Earth Summit 1992 Rio Declaration.

Health prospects anywhere in the world depend on sustainable development of our natural and social environment. Health cannot be separated from a myriad of environmental elements as diverse as air and fresh water, poverty and living conditions, sanitation, chemicals, diseases vectors, over consumption, under development, technology and trade.


Attaining the goal of healthy people in healthy environments requires far more than the application of medical technology or even the total efforts of the health sector working alone.


Integrated efforts by all sectors, organisations, individuals and communities are required to make socio-economic development sustainable and humane, ensuring a sound environmental basis for health.


Like all living beings, humans depend on their environment to meet health and survival needs.


Human health suffers when the environment no longer meets human needs, for sufficient and safe supply of food, water, sanitation and shelter, due to inadequate or poor distribution of resources.

Health suffers when people are exposed to hostile environmental agents such as microorganisms, toxins, armed enemies, or drunken drivers.


Human health is essential for sustainable development. Without health, human beings would be unable to engage in development, combat poverty and care for their environment. In turn, care of the environment is essential for human welfare and the development process. A healthy environment leads to a healthy population, as seen by the fact that an unhealthy environment leads to many environmentally related diseases and health problems.


In East Timor in 2000, the curative institutions - international NGOs and the military medical team of INTERFET - provided more than 690,000 consultations and curative interventions to the population. Poor environmental quality is directly responsible for around 70% of all preventable ill health in East Timor, with respiratory infections, diarrhoeal diseases and malaria heading the list. Acute respiratory infections among adults and children account for approximately 35% of total consultations and curative interventions; diarrhoeal diseases 30%; and suspected malaria 18% of total consultations. Furthermore, the outbreaks of dengue haemorrhagic fever, Japanese encephalitis and cases of filariases and visceral leishmaniasis which are vector born diseases are not uncommon in many parts of East Timor. It is estimated that 80% of children in East Timor have intestinal parasitic infections, which are also closely associated with the environment, particularly with poor sanitation.


The three main causes of death and disability in East Timor are; 1) diarrhoeal diseases due largely to contaminated food and water and lack of sanitation, 2) respiratory diseases particularly tuberculosis and pneumonia caused often by crowded unhealthy living conditions and 3) deadly malaria due to inadequate drainage and mosquito control.

Mortality in East Timor is contributed to by other mosquito borne diseases like dengue haemorrhagic fever and Japanese encephalitis, as well as by non-communicable diseases, chronic diseases, injuries from road traffic accidents and other conditions.

Let us look into the current environmental conditions in Dili. A rough estimate of the population of Dili is 120,000, which constitutes approximately 20% of the total population of East Timor. In Dili, little attention has been given to environmental issues in the post-crisis period, as major attention has been focused only on emergency and rehabilitation needs. Dili does not have any kind of sewerage system for wastewater treatment. The wastewater management practices in Dili consist of on site disposal facilities either with pit latrines or with septic tanks. The effluent from the concentrated pit latrines usually finds its way to the shallow groundwater, and the effluent overflow from septic tanks contaminates surface water drains. The existing latrines and septic tanks in the absence of a sewerage system, pollute the water coming from dug wells and shallow tub wells as well as polluting drain water. The high underground water table in the lower lying parts of Dili obstructs the sub-surface infiltration of wastewater and this situation becomes even worse during the wet season. Existing water supply service pipelines (catering to approximately 50% of population of the city) are quite often situated inside the road drains indicating the possibility of drain water getting into the leaking pipes.


The existing water and sanitation situation in Dili provides opportunities for contamination of drinking water by different infectious pathogens responsible for diarrhoeal diseases, viral hepatitis and other water-borne infections. In addition, absence of proper drainage and water storage systems are increasing the breeding sites for vectors of malaria, dengue fever, Japanese encephalitis, filariases and visceral leishmaniasis in the city and surrounding areas. The disease surveillance data indicate that during the year 2000, Dili district accounted for the following approximate percentages of total reported cases in East Timor; 30% of bloody diarrhoea cases, 27% of watery diarrhoea cases, 40% of dengue infections, and 18 % of malaria cases.


As has been seen in many developing countries, there is a possibility that the population of Dili will grow, attracting more migration of rural people to the city for employment. If plans for the water supply and sanitation system are not simultaneously developed, the population increase and the resulting environmental implications will further aggravate the environmental problems and other health hazards in Dili.

A water supply and waste management system is a complete process on its own and can be functionally categorised into;


(a)   source abstraction, treatment, and storage,

(b)   bulk or individual distribution, and

(c)    subsequent disposal of generated wastewater with suitable treatment.


Recently, the Division of Health Services and WHO made joint comments on a project proposal for Dili water supply, rehabilitation and improvement. This proposal only dealt with the work on source abstraction and did not cover the future implementation of water distribution or wastewater disposal.


The service ratio under the new system if implemented aims at 70%, which leaves the remaining 30% of the population dependent on the traditional sources such as shallow tub wells, dug wells and the small scale communal supplies that are scattered around the city: the system will have virtually no control over the quantity and the quality of water in use.

The daily per capita supply of safe water in the city is designed to be 249 litres, which is five times higher than the present supply of about 50 litres. The existing distribution networks would not withstand the sudden increase in the system supply and in consequence may give rise to more leaks, and burst mains. It is admitted in the proposal that if the wastewater in the city is not controlled properly then the anticipated increase in the supply may yield additional 2 mm of wastewater per day in the distribution area as surface runoff. Most of the overflows from the septic tanks at present are flowing freely to the surrounding ground or the open drains built for stormwater runoff. The artificial wetlands created by the excessive amount of the wastewater generated in Dili may contaminate the soil and surface water bodies and raise the groundwater table, imposing more difficulties for sub-soil infiltration and decomposition of the waste inside pit latrines.


The existing conditions in Dili with regard to the drainage and the on-site facilities for defecation reveal a very critical situation.


This does not mean that an improved water supply system for Dili is not an urgent need. The proposal is most welcome in this regard. However, our main concern is that the project proposal is incomplete, as it has not dealt with the simultaneous planning for the management of the water and subsequent wastewater problems. In such a situation, generation of additional wastewater may be responsible for further deterioration of the quality of water supplied, irrespective of the efforts to improve the quality of the bulk water supply.


The Division of Health Services and the World Health Organisation recommended to the ETTA Division of Water Supply and Sanitation Services, that the proposed water supply rehabilitation work including the distribution system in Dili should propose simultaneous development of a sewerage reticulation system and improvements to the existing drainage system. I hope that our recommendations will be taken into consideration and the project will be implemented accordingly.


Please remember the following commonly held wrong assumptions from the experiences of other countries:

        Improved water supply alone leads to better health. There is no need for sanitation;

        Sanitation improvement has minimal health benefits and no socioeconomic benefits;

        All good sanitation options are expensive and difficult to implement;

        Water, air, and soil are free goods and we should not have to pay for improving them;

        Safe and adequate water supply alone is a pre-condition for good sanitation;

        Message-giving will change behaviors;

        Traditional and cultural attitudes are barriers to good sanitation practices.


It is quite possible that you may have already heard such statements from individuals and organisations. However, you should bear in mind that the above statements are wrong assumptions. It is our responsibility to rectify by them, giving importance to sustainable, overall equitable sanitation to all people in East Timor.


WHO strongly recommends that any development project in East Timor should take into consideration the impacts on the health of the population and clear their proposals with health authorities. WHO is willing to provide the required technical support to the Division of Health Services in this important task.