The role of the South African Medical Research Council in reducing lead exposure and preventing lead poisoning in South Africa.

Even at low levels in blood, lead has been associated with reduced IQ scores, behavioural problems, learning impediments, aggression and violent behaviour. Since the 1980s, the South African Medical Research Council (SAMRC) has been investigating the sources of exposure to lead in South Africa (SA), the groups at highest risk of lead poisoning and a selection of the myriad associated health and social consequences. SAMRC research evidence contributed to the phasng out of leaded petrol, restrictions on lead in paint and other interventions. Subsequently, childhood blood lead levels in SA declined significantly. More recent studies have revealed elevated risks of lead exposure in subsistence fishing and mining communities, users of arms and ammunition, those ingesting certain traditional medicines, and users of certain ceramicware and artisanal cooking pots. Lead-related cognitive damage costs the SA economy ~USD17.7 (ZAR261.3) billion annually, justifying further SAMRC investment in lead exposure research in the country.

Public health lives: Gro Harlem Brundtland.

Health has been a deeply personal, professional and political dimension of Gro Harlem Brundtland's life. Her decision to study breast feeding while an MPH student at Harvard in 1964, or her desire to tackle tobacco being influenced by her father sending her as a 10-year old girl to buy his cigarettes at the local store, or her deeply personal family experience of mental ill health all led her to take actions on the global stage to address these and other issues that evidence showed would have global impact. Her impact on global health started with a commitment to make a difference in the lives of people, particularly those in greatest need.

Comparison of indoor air quality in electrified and un-electrified dwellings in rural South African villages.

UNLABELLED: A feasibility study was undertaken to assess the suitability of South African rural villages due to be electrified, for the purposes of undertaking a large-scale study of the impact of reductions in indoor air pollution on acute lower respiratory infections. As part of the feasibility study, quantitative assessments of indoor air pollution in non-electrified and electrified dwellings were performed. Concurrent measurements were made of levels of respirable particulate matter (RSP-stationary), and carbon monoxide (CO) (personal on children <18 months), as well as a stationary co-located with RSP) over a 24-h period in 52 un-electrified and 53 electrified dwellings. The proportion of dwellings with a detectable 24-h concentration of RSP was significantly higher in un-electrified (48.1%) than electrified dwellings (24.5%) (chi(2) = 6.30 on 1 d.f., P = 0.012). In addition a Kruskal-Wallis test (adjusted for ties) showed that the distribution of RSP differed between un-electrified and electrified areas (Kruskal-Wallis chi(2) = 8.20 on 1 d.f., P = 0.014). In those dwellings where some RSP was detected, the amount was on average higher in the un-electrified areas (mean 162 microg/m(3), median 107 microg/m(3)) than in the electrified areas (mean 77 microg/m(3), median 37.5 microg/m(3)). Stationary (kitchen CO) levels in un-electrified dwellings ranged from 0.36 to 20.95 p.p.m. However, in electrified dwellings, kitchen levels ranged from 0 to 11.8 p.p.m. When mean concentrations of CO were compared between electrified and un-electrified dwellings using a two-sample t-test (on log-transformed data), there was overwhelming evidence (P = 0.0004) that the mean level of log (CO) in the kitchen was higher in the un-electrified areas (1.25 vs. 0.69) and also overwhelming evidence (P < 0.0001) that the mean level of log (CO) on the child was higher in the un-electrified areas (0.83 vs. 0.34). Of importance in terms of both policy and for a potential future large-scale study, is that measurable significant differences in indoor pollutants between electrified and un-electrified dwellings during summer were found in spite of only partial transition to electricity use for cooking in electrified villages. PRACTICAL IMPLICATIONS: It is estimated that at least two-thirds of all households in the developing world are still primary dependent on biomass fuels and coal. This situation applies to 59% of rural households in South Africa. In the last decade a program of providing electricity to three million homes has been underway in South Africa. Among others this intervention aims to reduce exposure to pollutants from burning biomass fuels and reduce detrimental health effects, especially in young children. This study provides scientific evidence that electrified homes in South African villages have lower levels of air pollution (RSP and CO) relative to their non-electrified counterparts.

A survey of blood lead levels among young Johannesburg school children.

Studies conducted around the world have established beyond doubt that elevated childhood blood lead levels may lead to detrimental health effects. Research has shown that certain groups of South African children are at particular risk of elevated blood lead levels. Johannesburg is the largest urban complex in southern Africa, with a population of around 3 million and extensive industrial and manufacturing activity. Among the challenges posed in the city are rapid urbanization, extensive poverty, and inequity. Little information on the blood lead distribution of Johannesburg children is available. This study was undertaken to determine blood lead levels among children living in three areas of Johannesburg: inner city suburbs and the low-income townships of Alexandra and Westbury to the north and west of the city center, respectively. The results indicated that blood lead levels ranged from 6 to 26 micro g/dL, with a mean level of 11.9 micro g /dL. The blood lead levels of 78% of children equaled or exceeded 10 micro g/dL, the current international action level. Maternal educational status, the presence of smokers in the home, and living in an informal dwelling were among the factors associated with elevated blood lead levels.

Distribution of blood lead levels in schoolchildren in selected Cape Peninsula suburbs subsequent to reductions in petrol lead.

OBJECTIVE: To determine blood lead levels among children attending schools in selected Cape Peninsula suburbs, and to assess the impact of a reduction in the lead content of petrol. DESIGN: A cross-sectional analytical study of children's blood lead levels and associated risk factors. SETTING: Selected inner city, suburban, and peri-urban schools in the Cape Peninsula, expected to have differing levels of environmental exposure to lead. SUBJECTS: Grade 1 schoolchildren for whom prior written parental consent had been obtained, and who were present at school on the day of the study. OUTCOME MEASURES: Blood lead levels (microgram/dl), associated with a wide range of potential risk factors. RESULTS: Median blood lead levels in suburbs varied from 14 to 16 micrograms/dl, the lowest levels occurring in the peri-urban suburb and the highest in the inner city suburb. Within the inner city suburb of Woodstock, variations in mean blood lead concentrations among schools were substantial, varying from 13 to 19 micrograms/dl. Overall, no change occurred in blood lead levels in this suburb subsequent to the lowering of the lead content of petrol. CONCLUSION: Every effort should be made in South Africa to control sources of lead in the urban environment. The study will serve as a useful baseline against which to measure the impact on blood lead levels of further actions which have been taken to promote the use of lead-free petrol in South Africa.

Environmental lead exposure: a public health problem of global dimensions.

Lead is the most abundant of the heavy metals in the Earth's crust. It has been used since prehistoric times, and has become widely distributed and mobilized in the environment. Exposure to and uptake of this non-essential element have consequently increased. Both occupational and environmental exposures to lead remain a serious problem in many developing and industrializing countries, as well as in some developed countries. In most developed countries, however, introduction of lead into the human environment has decreased in recent years, largely due to public health campaigns and a decline in its commercial usage, particularly in petrol. Acute lead poisoning has become rare in such countries, but chronic exposure to low levels of the metal is still a public health issue, especially among some minorities and socioeconomically disadvantaged groups. In developing countries, awareness of the public health impact of exposure to lead is growing but relatively few of these countries have introduced policies and regulations for significantly combating the problem. This article reviews the nature and importance of environmental exposure to lead in developing and developed countries, outlining past actions, and indicating requirements for future policy responses and interventions.

Intersectoral action for health: a cornerstone for health for all in the 21st century.

For many decades, intersectoral action has been recognized as being of critical importance for the promotion and the protection of human health. In 1977, the World Health Assembly identified intersectoral action as an important component in achieving the goal of Health for All by the Year 2000; this has since been reemphasized by a number of international conferences. A major conference entitled "Intersectoral action for health: a cornerstone for health for all in the 21st century" was held in Canada in 1997. Described as "intersectoral action in motion", the conference assessed problems and progress, identifying future policy and strategies appropriate for the 21st century. The main conclusion of the meeting was that while intersectoral action is working, the successes and failures need to be further analysed, assessed and the lessons learned widely disseminated. Strategies need to be modified, adapted and implemented at global, national and subnational levels, in ways that are appropriate to different country situations and contexts. The full potential of intersectoral action for achieving health for all in the context of sustainable human development has yet to be realized.

A study of the distribution of urban environmental lead levels in Cape Town, South Africa.

Epidemiological studies which have attempted to quantify the relationship between environmental lead and blood lead levels have been beset by numerous methodological problems, one of which has been the difficulty in assessing environmental exposure to lead. In Cape Town, South Africa, a comprehensive environmental lead monitoring programme was instituted in an inner city suburb where a blood lead screening study was in progress. The objective of the study was to examine the spatial and temporal variation in environmental lead levels, and to examine the role of potential influencing factors such as traffic. Results revealed substantial intra-urban variations in air lead levels, with annual means varying from less than 0.5 to over 2 micrograms/m3 at individual sites. Traffic density and the distance from heavily trafficked roads were important influencing factors within the area. Considerable seasonal as well as daily variations in air lead levels were also documented, and air lead levels were positively associated with dust lead levels. The spatial and temporal variations in environmental lead have implications for air monitoring strategies and epidemiological studies concerned with the relationship of exposure to lead and the health impact on populations. Micro variations in exposure need to be taken into account assessing exposure to environmental lead in epidemiological studies, in light of the considerable variations which may occur.

The Greater Johannesburg Healthy Foods / Markets Programme.

PIP: This article discusses the World Health Organization's (WHO) Healthy Cities Project's (HCP) Healthy Foods/Markets program in Johannesburg, South Africa, among food vendors (FVs). Food contamination is a major contributor to illness, a compromised nutritional status and less resistance to disease, and loss of productivity. Health risk is related to the potential of food to support microbiological growth. Foods can have a high or low health risk. Food risk is related to food type, pH, method of preparation, water availability, handling, exposure temperature, and holding time. Food vending has increased in South Africa, and may employ 6-25% of the labor force. Street food is exposed to climate and temperature, unsafe water supplies and sanitation, and pests. A study conducted among 116 FVs in Johannesburg, assessed the microbiological food quality and potential risks. Formal FVs were less likely to be women and had more vending experience than informal ones. All food from informal FVs was hot, while food from formal FVs tended to be cool. 73% of formal FVs stored leftovers for sale the next day. FVs used some precautions in food preparation. 15% of street FVs, and 13% of formal FVs, had contaminated foods. Formal traders had better hygiene practices, but greater storage that would contribute to contamination. Street FVs need access to safe, ample supplies of water, sanitation, and waste disposal mechanisms. Authorities will be implementing the WHO Hazard Analysis Critical Control Point for low-cost, effective surveillance of street foods.^ieng

Environmental planning and management in Greater Johannesburg.

PIP: This article describes the actions among urban environmental, management, and development planners in Greater Johannesburg, South Africa. Initiatives, such as the Healthy Cities Project and Model Communities, are being integrated into an environmental management and development approach that attains the goals of Agenda 21. Greater Johannesburg has housing shortages and homelessness. Priority needs include the areas of housing, water, electricity, public transportation, and sanitation. Clean water and air are inequitably distributed. Other key environmental problems include illegal dumping, inadequate waste disposal, poor environmental hygiene in overcrowded inner city areas, lack of open spaces, flooding, and water scarcities. The newly formed metropolitan authority offers opportunities to improve coordination and integration of environmental problems. Stakeholders from government at all levels, politicians, nongovernmental organizations, and the business sector formed an intersectoral, interdepartmental environment management committee in 1995. Stakeholders will integrate Agenda 21 within broader urban development plans and processes. The executive committee and the full council approved a set of guiding principles on environmental policy and an administrative framework for management. Four workshops were held to ensure a participatory consultation process in 1995. The WHO Collaborating Center for Urban Health will be used to facilitate the work of the Greater Johannesburg Metropolitan Council. Changes are being made in the way local governments work.^ieng

A new approach towards environmental management in greater Johannesburg.

PIP: This article describes the efforts of the South African Greater Johannesburg Transitional Metropolitan Council to more equitably distribute resources to areas of greatest need and most severely affected by environmental damage. The Council increased coordination within the metropolitan government to address local environmental problems and increased awareness and expertise in environmental management among nongovernmental groups and individuals within government and development institutions and within local planning and environmental forums. The Council also created opportunities to expand environmental data collection in Johannesburg and to reintroduce indigenous nature and wildlife. Environmental development initiatives were established as early as 1990. The city initiated a Health Cities Project in 1993. The Council established an Environmental Management Committee, which makes recommendations to the Executive Committee and ensures a sustainable, supportive, and healthy environment. A preliminary situational analysis revealed data inadequacies, lack of coordination, lack of enforcement, and lack of public awareness. Working groups were established to deal with pollution, sanitation, food safety, hazardous substances, and chemical safety. The environmental management committee formed viable partnerships with key health and medical people and joined the Global Environmental Monitoring Systems (GEMS) program of WHO. The committee plans to develop a new administrative framework, environmental policy and management system, state of environment reports, uniform legislation, and other efforts.^ieng

The health effects of exposure through swimming in South African marine waters: an overview.

PIP: This study evaluated the health effects of exposure to pathogenic microorganisms in South African marine waters during 1990-94. About 20% of South Africa's coastline is used for recreational purposes. The prospective study was conducted on 4 beaches and a tidal pool in the Western Cape Province in 1990. The sample included about 16,000 participants willing to provide information at the time of contact and at a follow-up date. The aim was to assess the health risks, to establish the relationships between swimming and water quality and health outcomes, and to recommend appropriate microbiological indicators. Prospective trials were discretely carried out during the peak holiday season. The trials relied on methods established by Cabelli (1982) and endorsed by the US Environmental Protection Agency (EPA) in 1986, and the World Health Organization in 1991. Water quality samples were obtained on recruitment days for fecal coliforms, E. coli, fecal streptococci, staphylococci, and coliphages. Findings indicate that the microbiological quality of the water on the 4 beach sites complied with both existing South African standards and US EPA guidelines. The tidal pool showed signs of pollution with fecal coliforms, fecal streptococci, and staphylococci. Water quality varied on different days. Further analysis is being conducted on the different levels of water quality. All sites showed an increased health risk for swimmers compared to nonswimmers. Site 2 showed a statistically significant risk. A prior pilot study found some evidence of a relationship between swimming-related illness and water quality.^ieng

Towards a higher priority for health on the development agenda.

Over the last few years major international agencies (particularly the World Health Organisation and the World Bank) have increasingly recognised that investing in health is crucial for development. Development policies have the potential to enhance or impede progress in achieving Health for All. At the macro-economic level it is broadly recognised that the state of the economy of a country has a strong influence on its health level. The growing number of the population below the poverty line in sub-Saharan Africa is expected to have a substantial impact on health in the future. Further, structural adjustment programmes' impact on health has yet to be adequately evaluated. Rapid population growth in sub-Saharan Africa needs to be innovatively addressed as a matter of extreme urgency. The education of women is strongly related to child survival. Over the next few years the prospects for global disarmament are increasing. Options for using both the technology, financial savings, and personnel for improving health need to be investigated. A broader range of policy options for health needs to be considered by governments. A greater focus on information, education, and communication for health is needed that draws upon both the private and the public sector; greater use of regulation and legislation as solid policy instruments, for example, for pollution control, and banning tobacco and alcohol advertising, is required. Financial strategies using a combination of taxes and subsidies have not been adequately used in developing countries. The previous emphasis on urban-based expensive hospitals has proved to be inappropriate, resulting in severe inefficiency and inequity in the health systems of developing countries. Greater attention must be given to funding those areas with a high potential for positive externalities and that yield public goods. The final policy instrument involves using research to extend the options for intervention choice.

PIP: The growing number of the population below the poverty line in sub-Saharan Africa is expected to have a substantial impact upon health in the future, while the impact of structural adjustment programs upon health has yet to be adequately evaluated. Major international agencies such as the World Bank and the World Health Organization are increasingly recognizing that investing in health is crucial for development. Options for using technology, financial savings from increasing global disarmament, and personnel for improving health need to be investigated, while a broader range of policy options for health needs to be considered by governments. Information, education, and communication strategies for health which draw upon both the public and private sectors must be put in place. Moreover, health-related regulation and legislation are called for with regard to issues such as pollution control and tobacco and alcohol advertising. Combining taxes and subsidies has not been adequately used in developing countries. There is also a great need to reorient away from hospital-based health care systems. The authors look at the emerging consensus on the need to invest in health, the national and international impact of policies which affect health, and their implications. Examples are drawn mainly from developing countries.

Morbidity among bathers exposed to polluted seawater. A prospective epidemiological study.

As the first phase of a major programme to develop epidemiologically derived recreational water quality criteria for South Africa, a preliminary epidemiological-microbiological study was conducted in Cape Town during February and March 1990. Serial trials were carried out at a clean and at a relatively polluted beach over weekends. Participants were recruited at the beach, at which time information on swimming status and sociodemography was obtained. This provided for a beach-going but non-swimming control group. Symptoms which developed subsequent to the beach visit were obtained by follow-up telephone interviews conducted 3-4 days later. Water samples collected on trial days both before and during maximum swimming activity, were analysed for enterococci, faecal coliforms, staphylococci, coliphages and F-male-specific bacteriophages. Significant differences in the indicator levels at the beaches were observed. An excess in gastro-intestinal, respiratory and skin symptoms were found among swimmers relative to non-swimmers at the polluted beach. Although not statistically significant, the results are suggestive of a relationship between swimming-associated illness and water quality. The study demonstrated the feasibility of the methodology and the results of the overall programme will form the basis for the development of epidemiologically derived recreational water quality criteria for South African beaches.