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Chapter 3

LESSONS AND SUCCESSES

The Ecohealth approach has been tested in three major environments that pose serious threats to the health of both ecosystems and people, especially in developing countries: mining, agriculture, and the urban regions.

In each of these sectors, the ecosystem approach to human health has lived up to its potential. And in each can be found the three methodological pillars described in the previous chapter, harbingers of the approach's success and of the identification of concrete, feasible solutions.

Mining

The economy of developing countries depends more than that of most of their industrialized counterparts on the exploitation of natural resources -- in fact, that is one way of defining them. In more than 30 developing countries, for instance, mining accounts for 15­50 percent of national exports, while in another 20 it still plays a significant economic role. Small-scale or artisanal mining, most of which is concentrated in the countries of the South, provides work for 13 million people and affects -- positively or negatively -- the lives of between 80 and 100 million people.

The spectacular growth of mining around the world exerts enormous pressure on ecosytems, which can have harmful repercussions on human health. In Brazil, for instance, the 900 km corridor carved out of the jungle from the Atlantic Ocean to the huge Carajas mine has had an impact on more than 300 000 km² of land. The discovery of gold alongside the Tapajos River in Brazil in 1958 provoked a "rush" of some 200 000 prospectors and miners into an undeveloped area totally lacking a sanitary infrastructure.

The life cycle of any mine generally consists of three main phases -- exploration and construction, operation, and closure. Each phase presents its particular threats to the health of ecosystems and human populations.

Exploration and construction cause mainly biophysical damage. Low-altitude exploration flights disturb the local people and frighten wildlife. The excavation process causes erosion, makes it easier for pollutants to reach watercourses, and alters animal behaviour patterns. Road-building also leaves scars that often betray the mine's presence in an area. This preliminary phase of a mine's life cycle raises the population's hopes of gainful employment, but it also creates insecurity.

In small-scale and artisanal mines, environmental damage is often due to the high cost of "clean" technologies as well a to a certain indifference on the part of the exploiter. Gold mines, for example, have a number of impacts on the surrounding ecosystem: water is contaminated by metals, vegetation is destroyed, and soil is exposed to erosion. The surrounding communities, for their part, must deal with increased rates of alcoholism, violence, and prostitution. In addition, all types of mines generate potentially dangerous gaseous, liquid, and solid wastes. As a result, many rivers in Africa, Latin America, and Asia have now been declared biologically dead.

Finally, all too often the closing of a mine simply means it is abandoned. It is rare in developing countries for governments to have the means to rehabilitate mines abandoned by the private sector. The situation is even worse in the case of artisanal mines that are often abandoned without any prior planning.

In a mining environment, human health, both physical and mental, is subject to constant assaults. The most common are respiratory irritants, noise pollution, constant vibration, and contaminated drinking water. In many instances, very little is actually known about the various contaminants, their dynamics, and how they are passed to humans. For example, two Ecohealth projects -- one dealing with mercury in the Amazon, the other with gold in Ecuador -- have shown that the local population's exposure to contaminants does not only come as a result of industrial activity. In fact, agricultural practices such as slash-and-burn cultivation and mountainside cultivation can also release naturally occurring toxins into the environment as a result of soil erosion. This places a double burden on precarious communities, some of which are often located far from the mines.

Mining operations sometimes restrict people's access to arable land, reducing the production of fresh food, and thus harming human health. Local inhabitants also resent the sudden, massive influx of newcomers, precipitated by the opening of new roads: this can lead to conflict. The opening of a mine also affects local women in some countries because they are banned from working in the mines. In several cultures, the presence of a woman in a mine is considered bad luck. This exclusion reduces women's earning potential and thus their influence within both their families and their communities.

The link between the environment and human health is particularly critical in a mining environment. This is why the ecosystem approach to human health, especially through community participation, emerges as a valuable tool for effective action.

Traditionally, studies of the impact of mining on human health and the environment have used a unidisciplinary approach that focuses on a particular issue. For the past 20 years, considerable research has been conducted on environmental pollution, community health, and socioeconomic development. Usually, these specific analyses of particular problems do not make it possible to characterize all facets of a problem in space and time. An enormous gap exists between analysis and effective remedial action.

In countries of the South, conditions in the mines often leave a lot to be desired: the heat, inadequate ventilation, and constant threat of cave-ins create an oppressive working environment for ill-equipped miners, some of whom are very young boys. Wages are low, irregular, and uncertain.

Processing ore also entails its particular share of problems. Miners who use mercury to extract gold often suffer from troubled vision, tremors, and memory loss caused by mercury's toxic effects. Despite the risks for human health and the environment, mercury's ease of use and low cost make it irresistible to gold prospectors. Even small extraction facilities to which miners sometimes bring their ore use techniques that release lead, mercury, manganese, and cyanide into rivers and streams. Within a few years, a charming area recreational area has become a lifeless zone that no one dare use.

In the mining towns of Zaruma and Portovelo in southern Ecuador, IDRC is supporting the Fundación Salud Ambiente y Desarrollo (FUNSAD, an environmental health and development foundation), an NGO that has committed itself to the Ecohealth approach. The foundation has assembled a transdisciplinary team of three doctors, two geologists, a sociologist, and a community development worker. In addition, 12 community members work as project associates, collecting information on the lifestyle and work of 1 800 inhabitants. The third group of key players represent municipal government.

In both cities, people knew that the river was being contaminated by the small ore-processing facilities. They also believed that the water further downstream, below the rapids, was not polluted because of the rapid current. To everyone's surprise, analysis showed the presence of lead many kilometres below the rapids and the processing operations. It seemed impossible for the lead from the factories to be found so far from the mining zones.

Now, it is suspected that lead is released into the environment by land clearing and soil erosion resulting from mountainside cultivation, just as the erosion of the banks of the Amazon's tributaries releases mercury. FUNSAD is also examining atmospheric pollution, especially the effect of climate on pollutant retention in a valley in the heart of the Andean cordillera. In addition, the hypothesis that the lead might come from a contaminated aqueduct has not been eliminated. In addition to these findings and hypotheses, the project has led to talks between the local authorities, the miners, and the communities to find solutions. In southern Ecuador, the transdisciplinary approach has led to the identification of problems that would otherwise have gone unnoticed in a more traditional research context.

Moreover, the use of local people to conduct the interviews proved to be a positive experience. The interviewers did not simply act as sources of data, but involved themselves thoroughly in the process, going so far as to propose solutions. They developed their own vision of the project, including aspects that the researchers had not anticipated, such as controlling the municipality's practice of dumping garbage in the river and implementing an environmental code to reduce the discharge of mining residue into the water. The data-collection team thus transformed itself into a genuine community action group.

This experience shows that the participatory approach works. But the initiative has to germinate within communities and the research team must remain vigilant to ensure that it does not suffocate initiative by adhering at all cost to the project's initial parametres. "What pleases me most in this project," explains Cumanda Lucero, one of the interviewers, "is the feeling of belonging to the community and the hope of being able to improve the situation." FUNSAD's success attests to the principle that "development comes from within."

One of the Ecohealth approach's main challenges in the mining sector is bringing together industry, government, and local community representatives to consult on common problems. Attracted by new legislation in developing countries that throws open the country's doors or by the abundance of mineral resources that can be extracted at very low cost, senior mining companies and a host of junior companies from countries like Australia, Canada, and the United States are investing in new operations. Here as elsewhere, however, each heady period is inevitably followed by a depression. For example, for several years starting in 1993, Latin America experienced a real boom in mining activity that was largely driven by junior firms from Canada.

Since governments in developing countries are often very centralized, local and regional authorities have little power over mining activity. Recent underfinanced efforts at decentralization have faltered, notably because local and regional officials, who have traditionally been excluded from the decision-making process, lack training for their new roles. It is thus difficult, if not impossible, to implement policies formulated further up the hierarchy at the local level, regardless of how enlightened these policies might be.

The situation is complicated by the vulnerability of the populations affected by these new mining activities. Mining stands a good chance of aggravating already difficult situations in which poverty, high population densities, and the tropical climate conspire to contaminate the food chain. The need for economic development is great, but a disorganized exploitation of natural resources is likely to deepen poverty. Unfortunately, foreign mining companies have received little training in dealing with social issues in these countries, which are financially so welcoming.

Some companies resist requests for local consultations to avoid costly procedures, especially since mining exploration is always a gamble. Even though some companies are beginning to recognize the importance of local consultation, they do not know how to initiate genuine community participation. A first step would be to include social scientists in mining management teams that until now have almost always been composed solely of geologists and engineers. A further step would be to adopt a transdisciplinary approach.

Moreover, small-scale and artisanal mining operations are booming around the world. They represent a possible way out of poverty for some 13 million untrained workers. But working conditions in these operations remain very hazardous and their impacts on the environment and human health are often devastating.

Governments, communities, and mining companies all face the same problem: a lack of tools for determining the real impact of mining, good and bad, on public health and welfare. Between 1997 and 2002, such tools were developed by a group of scientists from Colombia, India, and the United Kingdom. Specialists from the Tata Energy Research Institute (TERI) in New Delhi, India, then tested these tools in the State of Goa in western India, an area where iron ore has been mined for decades. The Indian team taught the community, the authorities, and the industry how they could use the tools to clearly measure the long-term impact of mining operations on community health and well-being. It would then be up to decision-makers to modify their policies accordingly.

Box 5. The mines of Goa

Intensive mining has been underway in Goa for more than 35 years. Because of the employment created and the services provided, the local economy has performed very well indeed. Nevertheless, hillsides have been flattened and forests cleared. People complain of dusty air, dried-up wells, and rain that washes mining waste into rivers, streams, and fields.

A survey of the inhabitants of 57 villages, as well as of mining companies and government representatives, identified common concerns: insufficient compensation for land taken; degradation of air, water, soil, and forests; health problems like diarrhea, jaundice, malaria, flu, and coughs; the eventual closing of the mines; and insufficient investment in recreation, education, and health (Figures 3 and 4).

On the basis of this inventory, a team from the Tata Energy Research Institute of New Delhi identified indicators of well-being and quality of life that all stakeholders accepted. With IDRC assistance, the team succeeded in determining social and environmental performance indicators that, for the first time ever, measured the economic, environmental, and social costs of mining operations. The team also developed optimal revenue criteria to ensure the long-term economic sustainability of mining operations. It can already be stated that the mines' contribution will only be positive if part of their revenues is used to reduce the mines' environmental and social costs for future generations.

These indicators do not solve all the problems, but they do help resolve disputes, make decision-makers more sensitive to everyone's needs and preoccupations, and foster responsibility and transparency. A space for discussion has been created. That's a good start.

Figure 3. Stakeholder map for the mining industry in Goa, India (source: Noronha 2001).

Figure 4. The central intersection shows concerns that are common to the key stakeholders in the Goa mining industry (source: Noronha 2001).

Agriculture

Agricultural production causes profound transformations in the physical and human environment. About 11 percent (1 440 million hectares) of the Earth's land is arable; this area is increasing at the expense of forestland. However, this agricultural land is often poorly managed. For example, excessive use of pesticides and fertilizers, salinization, contamination by heavy metals, and soil depletion have now put about 2 percent of the Earth's lands out of production. This means that more than 10 million hectares of the Earth's arable land have now been irretrievably degraded. Moreover, as pointed out by the WHO in its report entitled Health and Environment in Sustainable Development the fluctuations in demand for various agricultural products brings about changes in the ecosystem that affect the health of farmers and their families. Here are some examples, all of which affect the health of both people and ecosystems:

• Rice is increasingly replacing traditional cereal crops. But the new rice fields are ideal habitats for the vectors of diseases like malaria and schistosomiasis.
• Changes in the size of livestock herds can, in turn, modify the population densities of biting and blood-sucking insects.
• The use of new pesticides entails new risks of poisoning.
• Sometimes, we even go in circles. In Southeast Asia, after deforestation destroyed the habitat of the most important vector of malaria, new plantations of rubber trees, oil palm, and fruit trees recreated even more favourable conditions.

In the agricultural sector, the Ecohealth approach aspires to create synergy between the improvement of agricultural practices and the improvement of human health while ensuring the ongoing viability of agricultural ecosystems.

The Ecohealth approach uses the agroecosystem as the starting point to demonstrate how its judicious management is more cost-effective in promoting human health than the simple juxtaposition of biomedical programs. An "agroecosystem" is simply a coherent geographical and functional entity where agricultural production takes place. Agroecosystems consist of living and nonliving components and their interactions. The exact limits of a given agroecosystem are difficult to determine since they depend on the particular question being studied. They can be the boundaries of a farm, a community, a catchment area, or even an ecological region. Dynamic systems, they are affected by factors such as the movement of workers, input of crop seeds and fertilizers, erosion, and seasonal pest infestations. Agroecosystems currently occupy 30 percent of the world's land.

It is not always easy to convince the communities in difficulty that the proposed solution to their health problems is not large-scale vaccination or some other modern medical program, but simply better management of their natural resources. However such an effort is worthwhile, as shown in the health pyramid (Figure 5). Instead of targeting the small fraction of the population that is severely affected by a given illness -- and achieving a very relative success rate -- the aim is to attack the root cause of health problems and thereby protect a larger number of people from illness.

Figure 5. The health pyramid.

Problems linked to pesticides, vector-borne diseases, and malnutrition abound in countries of the South. The poisoning of farm labourers, the explosive increase in the number of malaria cases from the digging of irrigation canals, and the impact of monocultural food production on the quality of people's diets -- all are striking examples of crucial problems that can be addressed using an approach that takes the link between ecosystem and human health into account.

The Ecohealth approach has already borne fruit in situations involving each of these problems. In the Mwea region of Kenya, better control of the malaria-carrying mosquito has been achieved by modifying agricultural practices (Box 6). In Oaxaca, Mexico, deliberations involving scientists, community groups, and government decision-makers have led to the introduction of community actions that have essentially wiped out the region's use of DDT (Box 7). In the highlands of Yubdo Legabato, Ethiopia, extensive community involvement has enabled the local population to break the vicious cycle of poverty and malnutrition (see Box 2, p. 19).

Most of these successful actions are not new. Their effectiveness is, however, in large part due to the adoption of a transdisciplinary approach in identifying problems and applying various solutions.

Box 6. Monoculture and health in Kenya

In Kenya, malaria kills between 75 and 100 children every day. Traditional programs to fight this disease have failed. In the Mwea region, the immense tracts of rice paddies that are covered with water six months of the year offer an ideal habitat for mosquitoes. The community has responded with insecticides and antimalarial drugs, but both the mosquitoes and the parasites have become more resistant. Clearly, regardless of cost, another way of dealing with this health problem needs to be found.

After participating in a preproject workshop, a team of specialists from various disciplines launched an Ecohealth study. The team trained 10 villagers as research assistants to interview the inhabitants of four villages on which aspects of their lives they believed were related to malaria.

It was discovered that a very large number of factors have influenced the spread of malaria in Mwea. First, a unique historical and social background has created political conflicts that have affected people's health. Local farmers had recently decided to take responsibility for irrigating their rice fields to escape government control that dated back to the British colonial regime and kept them impoverished. In practice, however, the change has led to agricultural chaos in which farmers plant when and where they want. As a result, the mosquito population and the number of cases of malaria have both increased significantly.

By taking into consideration the many health-related, economic, social, and environmental factors, the villagers and the research team have implemented solutions that improve the environment and do not resort to advanced medical technology. The rice-paddy flooding time has been reduced and the rice crops are now alternated with soybean crops that grow in dry conditions. The mosquitoes' habitat has thus been reduced and people's diet has improved. The children are no longer reduced to eating rice three times a day, a diet that leads to protein deficiency. The families have also been encouraged to surround their houses with plants that repel insects.

One surprising discovery was that the villages with the highest concentrations of mosquitoes were also those with the lowest rates of malaria. But these villages also owned the largest number of cattle. It appears that mosquitoes prefer cattle blood to human blood. That's not to say that increasing herd size would solve the problem, however. Strains of bacteria that kill mosquito larvae but are harmless to humans have been introduced into the water. It was also recommended that women and children -- the more vulnerable members of the population -- sleep under insecticide-treated mosquito nets.

The researchers have established a genuine relationship with the communities. The villagers now have greater self-confidence since they have realized that they can act effectively on their environment and improve their health.

With support from the International Water Management Institute, scientists and representatives from NGOs, government, and the communities are now working to disseminate the Mwea experience throughout Kenya. Through a framework called the System-Wide Initiative on Malaria and Agriculture (SIMA), they are institutionalizing the Ecohealth approach. The initiative's goal is to put in place ways of reducing malaria while improving people's health and increasing agricultural productivity. This program provides a research and development framework that generates practical short-term solutions while responding to the needs of targeted communities in both the medium and long term. The establishment of SIMA ensures the sustainability of the Ecohealth approach in Kenya.

Box 7. An end to DDT use in Mexico

In Mexico in the 1940s and 1950s, close to 24 000 of the 2.4 million people who caught malaria every year died as a result. Massive use of the powerful insecticide DDT was the linchpin of the government's effort to eradicate the disease. Over time, some progress was made against malaria, but the war was far from won. The use of DDT also posed its own threats to the health of the ecosystem. Moreover, as required by the North American Free Trade Agreement, Mexico had to completely eliminate the use of DDT by 2002.

To meet this challenge, an Ecohealth research project was set up to pool the knowledge of a team of specialists in epidemiology, computer science, entomology, and social sciences, from both government and academia.

This team has accumulated volumes of information about the prevalence of malaria in 2 000 villages. Data from powerful geographical information systems enabled them to conclude that mosquitoes do not travel very much. "If you have a place to lay your eggs and feed yourself, why go elsewhere?" explains Mario Henry Rodriguez, Director of Research on Infectious Diseases at the National Institute for Public Health (NIPH). In addition, as confirmed by Juan Eugenio Hernández, NIPH's Director of Informatics, it is now believed that "human beings are the vectors of malaria," which explains why more cases of malaria are found in villages located alongside roads.

With community help, the team studied the population's living conditions, including behavioural differences between men and women. It was found that while women are more likely to be bitten by mosquitoes early in the morning when they go to fetch water, the men are likely to be bitten in the coffee plantations at night.

Several preventive actions have been taken. The scientists have proposed a new insecticide that, unlike DDT, does not persist in the environment. They have also developed a more effective pump that can spray 40 homes a day instead of 8, and uses less insecticide. A new malaria testing kit now detects the presence or absence of parasites in a patient's blood in only a few minutes, unlike laboratory tests that take three to four weeks to confirm a diagnosis. Previously, the need to wait for test results forced the authorities to treat everyone who showed vague symptoms of the illness, such as a high fever or headaches. Now, volunteers administer these tests to the people in close to 60 villages. "We have given communities the means to take care of themselves," says Mario Rodriguez.

The fight against malaria in Mexico is now no longer solely the responsibility of government employees. Women also play a role by removing, every two weeks, the algae that harbour mosquito larvae in bodies of water. As a result, the number of cases of malaria in the state of Oaxaca has dropped from 15 000 in 1998 to only 400 today -- and all without using any DDT. "Our experience has taught us that we need to bolster the social science research component if we want to extend this program to other parts of the country, while maintaining it in Oaxaca. The challenge is to draw the lessons that will lead to application of the program on a much wider scale," says Dr Rodriguez.

The urban environment

At the current rate of urban growth, every year the Earth will welcome one new 10-million-resident megacity and about 10 other million-plus cities. In fact, most of the world's 6.3 billion people live in cities or their immediate vicinity. In developing countries, cities face immense and disheartening challenges. One hundred million newcomers flock to cities each year, many of them rural people in search of better living conditions.

In the ecosystem approach to human health, the urban environment is characterized as an ecosystem that is largely influenced by human activity. Its distinctive features are high population density, an established infrastructure, and a high level of social organization. Cities offer very specific challenges for the Ecohealth approach. Researchers studying human health and the environment in an urban setting need to be concerned about poverty, housing, security, human rights, and equity.

Until now, IDRC-supported urban Ecohealth projects have mainly dealt with capitals -- Kathmandu in Nepal, Mexico City in Mexico, and Havana in Cuba -- in addition to one project in the city of Buyo, Côte d'Ivoire. In these large agglomerations, many groups with diverse interests interact: the private sector, civil society, municipal authorities, different ethnic groups, castes, and social classes, men and women. All play a role in the management of the urban ecosystem. This complicates the implementation of effective remedial programs, as shown by an air pollution reduction project in Mexico City.

The air in Mexico City, situated 2 240 m above sea level in a large valley, often contains two to three times more pollutants than international standards deem acceptable. Launched in 2000, the 10-year PROAIRE program seeks to improve air quality sufficiently to reduce the rate of pollution-related illness and deaths. From the outset, it has taken for granted that the inhabitants of the world's largest megacity will need to change their living habits. Achieving this, however, first requires understanding clearly how the residents perceive the air pollution problem.

With this goal in mind, federal authorities called on several national and international organizations, including women's groups and other organizations concerned with health and the environment, to clearly identify the problem and develop actions to solve it. In a city as large as Mexico, it can be difficult to motivate people to act. Thus, in addition to determining people's perceptions of the causes and effects of air pollution, researchers also sought to determine what, if any, action they were willing to take to fight it.

The survey revealed a tendency to blame air pollution on factories. Only a few of respondents mentioned the role of car exhaust, which actually accounts for 75 percent of all harmful emissions. People say "Other people are mainly responsible: my neighbours, maybe, but not me, not my car. My family and lifestyle are not to blame," reports Roberto Muñoz of the Secretaria del Medio Ambiente, the organization that directed this IDRC-funded project. Most people admit to not taking any action to deal with air pollution, nor are they interested in participating in air-improvement programs. The government, they say, is in a better position to deal with the situation than they are.

To convince people of their responsibilities and their ability to improve the situation, community education programs were required. The researchers found that past government programs had been largely ineffective. To formulate effective approaches, 14 workshops, each consisting of 8­21 participants (homemakers, local leaders, and so on), were organized in six separate districts of the city. Together, researchers and community members developed training materials and programs that educate people not only about the scale of Mexico City's problem but also about concrete actions men and women can take in the home and community to help solve it -- for example, using public transportation and carpooling, reducing water and fuel consumption, and using organic products.

Because cities are social organizations that evolve very rapidly, both spatially and socially, community participation becomes all the more difficult to maintain. One effective way of promoting participation has been to target smaller communities within the city itself. In Mexico City, six districts were chosen to organize workshops. In Kathmandu, after consulting men and women from different castes, two neighbourhoods were chosen in which the key players and environmental factors harmful to human health had been accurately identified. In Cuba, it is the residents of a small Havana neighbourhood, Cayo Hueso, who have come together to find solutions to the problems of housing and poverty that affect their health.

In 1995, the inhabitants of Cayo Hueso decided to rehabilitate their historic neighbourhood: fewer than half the residents had access to drinking water, more than a third of the living quarters had been declared unhealthy, and infections like tuberculosis and sexually transmitted diseases were on the rise. Through a community organization called Taller Integral (integral workshop) the community channelled its efforts and those government organizations. "In this part of Cuba," says Mariano Bonet, leader of the IDRC-funded Ecohealth project, "scientists and the people are already closely connected because researchers from the country's National Institute of Hygiene, Epidemiology, and Microbiology, the main vehicle for government involvement, actually live in the area."

The government has invested in restoring the district's buildings and has improved the water supply and garbage disposal systems. Special areas have been built for young people and street lighting has been improved. "One of the challenges," adds Mariano Bonet, "has been to translate the technical aspects of the research into language that the community can easily understand, as well as to convert community expertise into indicators and specific activities."

In the end, people from all walks of life participated in the project, including older women who made sandwiches. These first efforts have led to better social planning, including programs for seniors that involve activities such as physical exercise sessions and self-esteem workshops.

Scientists monitor the complex interactions between the urban fabric and the population's health. For example, for the first time ever, a study has been carried out of the connections between people's quality of life and specific factors like street lighting, water availability, and garbage collection. These studies have been carried out by a team composed of doctors, engineers, a sociologist, a psychologist, an economist, and an architect. A comparison of the health of the residents of Cayo Hueso with that of the residents in another community that had not benefited from similar interventions revealed a definite improvement in the health of Cayo Hueso's teenagers, adult men, and older women. Equally significant: in the wake of this program, a woman now chairs the people's council of Cayo Hueso.

Because of the exemplary success of the Cayo Hueso program, IDRC is now funding Dr Bonet's team in a project to control dengue fever, a pressing health problem in Latin America and Asia that is closely linked to the environment.

In Côte d'Ivoire, Cuba, Mexico, and Nepal, women's associations have been integrated into the definition of the research question. Interestingly it appears that urban women organize themselves and defend their rights better than their rural sisters. To truly respect the principle of male­female equity, it is important to recognize men's and women's distinct roles and responsibilities and understand how each gender is affected differently. This principle also needs to be extended to all groups when necessary, as was the case in Kathmandu where rich and poor -- such as the untouchable street-sweepers -- live and work side by side.

Researchers funded by IDRC are now developing indicators that will make it possible to evaluate the progress achieved toward sustainable development and better human health in the cities. Although generic indicators have existed for many years, indicators better suited to the unique characteristics of individual projects are needed. In Cuba, for example, it has already been shown that certain indicators such as the incidence of asthma, the presence of street lighting, and the rate of economic and urban growth very much reflect the environment's health in relation to the health of its human inhabitants.

Box 8. Cleaning up Kathmandu, Nepal

Kathmandu, the capital of Nepal, is currently experiencing one of the fastest population growth rates in South Asia. The process of urbanization there has been speeding up since 1950 and is characterized by both modernization and under-development. In Kathmandu, a wealthy elite rubs shoulders more or less comfortably with poor people belonging to lower castes and ethnic minorities.

Between 1998 and 2001, an IDRC-funded Ecohealth research project led to a better understanding of the dynamics between the various sociocultural, economic, political, and environmental determinants of human health. Two Nepalese NGOs played a key role in this project: one focused on diseases that humans share with animals; the other concentrated on sociocultural aspects and community participation strategies.

In the two wards of the city chosen for the project, 57 different castes live and work side by side -- among them priests, peasants, artisans, butchers, street-sweepers, and hairdressers. The traditions imported from the countryside vary widely and are often incompatible with sustainable urban development. In the neighbourhoods studied, for example, 87 percent of households usually throw their wastes directly onto the street rather than into garbage bins. The street-sweepers, most of them women accompanied by their children, are responsible for managing the solid waste. Moreover, 96 percent of the butchers were not aware of the contamination dangers posed by meat wastes, and their butchering techniques facilitated the transmission of animal diseases to humans.

The organizations taking part in the projects have helped the government regulate animal slaughtering: it is no longer permitted to slaughter animals on the banks of the Bishnumati River or to use its water to clean dead animals. The government has also helped an entire population of homeless immigrants organize literacy classes and look after their own primary health care needs, except for cases that actually require a physician's attention.

The Kathmandu urban system turned out to be much more complex than originally imagined and the project clearly showed the importance of planning and acting in concert with onsite organizations. Dr D.D. Joshi, Director of Nepal's National Zoonoses and Food Hygiene Research Centre, believes that this project owes its success to a marriage of science and awareness of social dynamics, which the Ecohealth approach facilitated.

Comprehensible results, sustainable solutions

One of the most notable successes of the ecosystem approach to human health, as promoted by IDRC, occurred in the Amazon where it was discovered that soil erosion was the main cause of mercury contamination. The Ecohealth approach has also made it possible to test various short- and medium-term strategies that have already reduced the level of human poisoning. The great advantage of the Ecohealth method was confirmed by better community health.

During the project, the research team learned -- sometimes the hard way -- how to interact with local communities, then attract the interest of local decision-makers. Initially intuitive, this process developed and evolved because of the trust established between the partners. The input of new expertise, especially in the social sciences, as the research proceeded, played a crucial role. The challenge of how to involve decision-makers in the research process remains, but dialogue has been opened and the partners are actively looking for agricultural development alternatives for the region.

It was initially difficult to interest the local authorities in the project because they were not involved when it was launched. It must be recalled that the project was not transdisciplinary at the outset: fieldwork and the needs felt by the partners oriented its evolution. This clearly shows the pioneering role this team has played in introducing the Ecohealth research framework within IDRC.

The formulation and understanding of this particular problem evolved over time: even after 10 years there is room for improvement. During this period, many Canadian and Brazilian students were trained in the field and obtained their master's or doctoral degree. Currently, four Brazilian researchers are pursuing their doctorates on project-related topics. This has been one of the project's great successes: in addition to changes in environmental management and health care practices in the area, there is now a new generation of scientists to continue the work.

Before the arrival of the IDRC-funded team, several teams from Japan, Europe, and other parts of the world had worked in the project site but, despite their scientific competence, had failed to bring about any real change. In the IDRC-funded project, the ecosystem approach to human health led to improvements in the community's health as early as the third year, partly because of a change in the type of fish eaten.

In most countries where communities and groundbreaking teams have tried the Ecohealth approach, processes to improve environmental and human health have arisen. One of the main challenges then becomes how to apply the results on a larger scale.

Box 9. Mercury in the Amazon

In the mid-1980s, Brazilian physician and cardiologist Fernando Branches alerted the scientific community that one of his patients, whom he believed was suffering from heart problems, had actually been poisoned by mercury. In short order, several international research teams became interested in the problem. In 1995, an IDRC-funded team consisting of researchers from the Federal University of Para in Belem, Brazil, the Federal University of Rio de Janeiro, and the Université du Québec à Montréal (UQAM) made an astonishing discovery -- the mercury contamination believed to be due to traditional mining operations was actually much more closely linked to certain farming practices.

Since the 1970s, a genuine gold rush has taken place along the banks of the Tapajos River, a major tributary of the Amazon. The artisanal method used to extract the gold employs mercury: when the metal comes into contact with gold it causes it to melt and amalgamate. Easily recovered, this amalgam is then heated. The mercury evaporates, leaving behind the prospector's glittering reward.

The Canadian researchers and their Brazilian counterparts expected to see the level of mercury in the water decrease the further they moved away from the mining area. Surprisingly, however, the concentration in the water remained the same up to 400 km from the mining site. This clearly indicated that something other than mines was the source of mercury contamination.

From time immemorial, volcanoes have been spewing mercury, which eventually falls to the ground. More recently, industrial activity like waste incineration has also contributed. It is estimated that the very old soils in the Amazon basin have been accumulating mercury for 500 000 to one million years, but this mercury has remained locked up in the soil until recent times. Since the 1950s, new settlers, attracted by the availability of farm land, have cut down and burned more than 2.5 million hectares of Amazon forest, mainly along the rivers. The rain falling directly onto the soil has been washing the mercury into the rivers, where bacteria convert it into toxic methyl mercury. The bacteria then pass the methyl mercury onto smaller fish, which are then eaten by bigger fish that eventually end up in people's frying pans. Terminal predators, humans thus absorb the highest concentrations of mercury.

The Brazilian and Canadian researchers demonstrated that even though the mercury levels in the hair of the villagers taking part in the study were well within WHO standards, they showed signs of a loss of coordination, manual dexterity, and visual acuity.

It appeared that the quantity of methyl mercury in people's bodies was linked to their consumption of different types of fish, which varied from season to season. People who ate herbivorous fish were less affected than those who ate carnivorous fish, which contained the highest mercury levels.

The second stage of the project consisted of working with the villagers to find solutions. A close working relationship with village women as well as with local teachers, health workers, and fisherfolk was established. One of the results of this collaboration has been a poster, suggested by the community, that shows the various types of fish and their level of contamination. It is now common knowledge that it is better to "eat fish that do not eat other fish." The results are very concrete: between 1995 and 2002, mercury concentrations in the villagers' hair have dropped by 40 percent (Figure 6).

Figure 6. From 1995 to 2002 levels of mercury in the hair of people living by the Tapajos River dropped by 40 percent. (Source: Mergler, D., personal communication, 2003)

For several months, midwives kept an exact record of the food eaten by 30 village women. It was also discovered by analyzing segments of their hair -- each of which represents one month's growth -- that mercury levels were lower in women who ate more fruit. This led to identifying foods that are likely to lower mercury levels in the human body.

The villagers have also started to change their farming practices. Working together, researchers and local farmers identified crops that could improve people's diet while reducing the likelihood of further mercury leaching. The researchers have also worked with local fisherfolk to locate the sections of the river that are least conducive to the transformation of mercury into its toxic derivative, methyl mercury.

In collaboration with the people living alongside the Tapajos River, research is continuing to apply scientific findings to their lives and thereby improve their health and that of their environment.

Document(s) 6 of 7