Development for children's environmental health in South Africa: Past gains and future opportunities

ABSTRACT

In poorly resourced countries children may face multiple health risks associated with environmental hazards and under-development. It is estimated that exposure to harmful environmental factors (e.g. air pollution, poor water quality and harmful chemicals) accounts for 33% of the global burden of disease, with the highest burden being borne by children. While accelerated housing and settlement development over the past two decades has benefitted hundreds of thousands of young children in South Africa, large numbers continue to face major environmental threats to their health, some of which have hitherto been neglected. Such children are likely to be particularly vulnerable to the unfolding ramifications of climate change. In this light greater urgency and momentum is needed to improve living conditions and other socio-environmental determinants of children's health in South Africa and other under-resourced countries. Children should be a central focus for policy and development as our global society strives to meet the Sustainable Development Goals.

KEYWORDS:

• Children
• environmental health
• South Africa
• sustainable development goals
• climate change

‘There can be no keener revelation of a society's soul than in the way in which it treats its children.’ – Nelson Mandela (1918–2013)

1. Introduction

Children are uniquely vulnerable to environmental and developmental factors, especially in the places where they live, learn and recreate (Suk et al., 2003). Even at the pre-natal stage, periods of rapid growth and development have been identified, during which exposure to environmental hazards may pose particular risks of disruption of biochemical processes, with the potential for lifelong health consequences (Selevan & Kimmel, 2004). Children's incompletely developed metabolic systems, their natural propensity for exploratory behaviour, higher rates of respiration and ingestion, and higher potential for manifestation of diseases with long latency periods, all contribute to their increased exposure and vulnerability to environmental risk factors (NRC, 1993; Selevan & Kimmel, 2004; Kootbodien et al., 2012).

Children's environmental sensitivity is illustrated by estimates that globally, more than ten million children die each year, mostly in poor countries, from preventable causes (six of the poorest countries in the world account for 50% of all deaths among children younger than five years of age). South Africa ranks at 30 among 42 countries that account for 90% of deaths among children under the age of five years (Black et al., 2003; Plagerson & Mathee, 2012). Overall, it is estimated that exposure to environmental hazards is the cause of 33% of the global burden of disease (WHO, 1997), with the highest share being borne by children. The World Health Organization estimates that in South Africa environmental factors are associated with the deaths of 124 in 100 000 children under the age of five year (WHO, 2017). Locally, studies have shown that deaths from diarrhoea (most of which relate to development and hygiene factors such as sanitation and water) in children under 5 years old may be 10 times higher than in adults aged 25 years or older. Similarly, young children (< 5 years of age) are 33 times more likely to die from lower respiratory tract infections (mainly pneumonia) than older children (aged 5 to 14 years) (Bradshaw et al., 2003).

The most important environmental hazards to children's health are found in and around the settings in which they spend most of their time – their homes and schools (Chaudhuri & Fruchtengarten, 2005). Included are poor-quality housing, inadequate access to safe water and sanitation, and air pollution from the use of polluting fuels for domestic cooking and space/water heating. South Africa is one of the most unequal societies in the world (van der Berg, 2014), and has high rates of child poverty (UNICEF, 2011). Child poverty is highest in the provinces that are predominantly rural. The rural province of Limpopo, for example, has the highest level of child poverty (78.7%), while the rate in the Western Cape, where a considerably larger share of the population lives in urban areas, is 28.4%. These factors, together with rapid urbanisation and industrialisation, poor economic growth (associated with a growing informal sector and the proliferation of cottage industries [home-based work that may involve the use of hazardous materials]) and weak enforcement of environmental health policies and legislation (Papu-Zamxaka et al., 2010) have resulted in large numbers of South African children, especially the poorest, being at elevated risk of simultaneous exposure to multiple environmental hazards in and around their homes.

The First Inter-ministerial Conference on Health and Environment in Africa, held in Libreville, Gabon in 2008 called for greater inter-sectoral cooperation on ‘access to safe drinking water, hygiene and sanitation … and inadequate and poorly constructed  …  housing and waste management systems’. In 2010 Ministers at the Fifth European Ministerial Conference on Environment and Health agreed to work towards safer homes and address environmental health risks that affect children. Also in 2010, international housing and health experts called for strengthening of WHO guidelines on housing and health (http://www.who.int/hia/housing). Given the renewed global focus on the role of housing in health, especially in the context of a changing climate, it is timeous for the human settlements and child health sectors in South Africa to reflect on past mistakes, and grasp the opportunities inherent in future housing redress programmes to design and build neighbourhoods that prevent ill health and injury in children, and promote their ability to reach their full potential in life. In this article data from various sources are used to paint a picture of the key environmental causes of child deaths and disease in South Africa, by way of a contribution toward healthier and safer living environments for children.

2. Methods

The findings presented here are based on an analysis of census data and a narrative review completed in 2016. We extracted relevant data from the 1996 and 2011 South African census data to compare and assess variations in living conditions across the nine provinces (see Figure 1). Two research assistants under the supervision of AM and HAR entered the relevant data into a spreadsheet for the purposes of comparison and contrasting. Published peer reviewed studies between 1994 to 2016 were included in the narrative review. Search terms included children, environment, health, toxicity, housing, poverty, climate change and development. Studies undertaken in South Africa were included in the review, while studies/data without a focus on children, environment and health were excluded.

Figure 1. Map of South Africa illustrating provinces. (Source: https://www.brandsouthafrica.com/wp-content/uploads/2016/12/Map_of_South_Africa.jpg.

3. Profile of young children in South Africa

Population estimates for the year 2015 indicated that there were around 5.9 million children under the age of five in South Africa, accounting for 10.8% of the national population (SSA, 2015). This is an increase of 34% over the 4.4 million children counted in the census of 1996 (SSA, 2001). Forty three percent of children live in just two of South Africa's nine provinces: Gauteng (the smallest province by area) and KwaZulu Natal are home to around 1.2 million (or 20% each) and 1.4 million (around 23%) of South Africa's young children, while the Northern Cape (which has the largest land area) housed less than 2%. There tended to be a relatively high proportion of young children living in the least developed provinces: 12.4% of the Limpopo provincial population was under the age of five, compared to only 8.9% in Gauteng (SSA, 2012a).

3.1. The unequal distribution of morbidity and mortality in children

Over several decades the apartheid¹ system of government engineered economic hardship and inferior living conditions for the majority black population, resulting in their children unjustly bearing an elevated burden of associated environmental risk, and concomitant ill health and mortality. While diminished through accelerated housing and service-delivery programmes, for many children the status quo of unhealthy living and learning environments remains. Associated with factors such as population group, socio-economic status, governance and development practice, the place within which a South African child is born and raised continues to have material implications for his or her quality of life, health status and life span. For example, children born in the Western Cape and Gauteng provinces have a greater chance of living in dwellings supplied with water, sanitation and electricity. In the Western Cape 77% of dwellings have access to a piped indoor water supply and 90% use electricity for daily cooking. By contrast, in the Limpopo province, only 13% of dwellings have an indoor water supply and 64% use electricity for daily cooking (Nannan et al., 2012). Overall there is particular concern for children living in the predominantly rural provinces of KwaZulu Natal, Limpopo and Eastern Cape provinces. These provinces have amongst the largest and fastest growing child populations, the highest levels of use of solid fuels for daily cooking (and therefore elevated risks of exposure to indoor air pollution), the highest levels of use of unsafe water sources and the highest mortality rates from environmentally related conditions such as diarrhoeal disease (SSA, 2012b). Children living in settings of urban poverty may be subjected to high levels of air pollution from both indoor (daily cooking and space heating) and outdoor (industry and vehicular emissions) sources (Naidoo et al., 2013). Development differences across provinces may contribute to the large differences in life expectancy observed across provinces. Girls and boys born in the Free State province, for example, have respective life expectancies of 54.7 and 53.0 years, which is more than a decade shorter than girls and boys in the Western Cape (66.0 and 63.7 respectively for girls and boys) (SSA, 2015).

3.2. Housing and health in South Africa

During the first two decades of democracy, as part of a programme of infrastructural redress, around 2.8 million low-cost houses were built, the proportion of people without access to a basic water supply was halved and 3.8 million people were connected to grid electricity (SA, 2014). The impact of these improvements, together with broader access to basic health services and feeding schemes, are borne out by laudable improvements in child health indicators. For example, between 1990 and 2013, despite the devastating impact of an HIV/AIDS epidemic, the neonatal mortality rate declined from 20.3 to 14.8 per 1000 live births, while the infant mortality rate dropped from 47.0 to 32.8. Similarly, the under-five mortality rate decreased from 61.0 to 43.9 over the same period (WHO, 2015)

. The housing backlog, however, from decades of apartheid and colonialism, was huge, and together with natural population increase and influx, may explain why the 2016 Community Survey (SSA, 2016) showed that 13% of households in South Africa still live in informal settlements, that less than half have an indoor water supply or toilet, and that around 17% used fuels other than electricity for daily cooking (SSA, 2016). Such conditions of under-development, in a context of deep and persistent poverty, contribute to preventable illnesses such as diarrhoea and pneumonia still ranking among the top five causes of mortality in young South African children (Bradshaw et al., 2003). In 2007 alone, more than 61 000 South African children died before reaching the age of five. Around 44% of these deaths were from diarrhoeal diseases, acute lower respiratory infections (mainly pneumonia) and injuries (Nannan et al., 2012). Since all three of these causes of child mortality have a strong basis in environmental factors and conditions of under-development (unsafe water and use of polluting fuels for domestic purposes), most of these deaths may be considered avoidable.

4. Children's environmental health: The disregarded agenda

While undoubtedly constituting a fundamental starting point and making a significant difference, action solely on housing (shelter), water, sanitation and energy is insufficient for the provision of environments in which children's rights to a clean and safe environment are met, and in which they may grow up to be healthy and reach their full potential in life. Attention also needs to be directed to a range of additional environmental health risks facing children in their home and school environments, many of which have hitherto been relatively neglected. Box 1 gives an illustration of how South African children in settings of poverty may be exposed, simultaneously, to multiple environmental health hazards. Studies undertaken in certain areas indicate that around 20% of South African housing stock may be painted with lead-based paint (Montgomery & Mathee, 2005). Lead is associated with reductions in IQ, learning difficulties, poor school performance, and aggressive or violent behaviour in later life. Children living in homes coated with lead-based paint may be exposed to lead in indoor dust and play areas, and there is particular concern for children with pica for soil or paint (children who eat non-food substances) (Mathee et al., 2007). Regulations to control the use of lead of paint were promulgated in 2010, but there is little certainty at present regarding the extent of compliance amongst paint manufacturers, and old lead paint applied to housing and schools remains an important public health concern. Elevated lead levels have also been found in paint applied to school buildings, playground equipment and children's toys (Montgomery & Mathee, 2005; Mathee et al., 2007, 2009b). Children growing up in dwellings from which a cottage industry is operated may also be at risk. For example, studies have shown that 74% of children living in remote South African fishing villages, where subsistence fisher folk regularly melt lead to craft fishing sinkers, had lead poisoning (Mathee et al., 2013). In this regard, the absence of a national lead poisoning prevention strategy (including a national blood lead surveillance programme) in South Africa constitutes a lost opportunity to promote high levels of health and social well-being in children

Box 1. Case Study: Children’s Environmental Health In The Township Of Riverlea, Johannesburg

Between 2006 and 2016 a panel study was undertaken in the township of Riverlea, which is a low-cost housing development in the city of Johannesburg, South Africa, with the aim to assess and track changes in local living conditions and health status. Annually pre-structured questionnaires were administered to an adult member of resident households in a set of dwellings that was randomly selected at the start of the study. In addition, environmental media (such as water and soil) were sampled periodically to assess bacteriological quality or chemical composition. Riverlea was constructed in the early 1960s adjacent to a large mine tailings facility, and dwellings are small and basic, and initially had asbestos roofing installed; doors, windows and their frames were painted with lead paint.

Preliminary analyses of the panel study data indicate that children in the area live in poverty and poor-quality housing. For example, few households have any money saved, medical insurance or access to a computer. Around 59% were living in dwellings with leaking roofs, a third had peeling interior paint, levels of access to running hot water were low, and residents regularly complained of high levels of mine dust in the air on windy days. More than 40% of respondents reported problems with rodents, for which some regularly used pesticides. Arsenic levels in local garden soil were found to be in excess of international guideline levels, as were lead levels in the produce from a local vegetable garden. Over a one-year period around 6% and 8% of households respectively reported that a member had suffered a gunshot or stabbing wound, while 9%, 4% and 1% respectively had suffered a road traffic, burn and poisoning injury respectively. A third of respondents perceived crime to be worsening. Alcohol and drug abuse were perceived to be a major neighbourhood problem by 75% and 83% of respondents respectively. Ten percent of respondents thought that life was not worth living, and 6% of households had a member who had attempted or committed suicide.

The environmental and social context in which Riverlea children are born, live and educated indicate serious concerns for their physical, mental and social health, and are illustrative of many settings of urban or rural poverty in South Africa, where children may face, simultaneously, multiple environmental hazards to their health.

Source of information: (Mathee et al., 2002; Mathee et al., 2009a; Plagerson & Mathee, 2012; Mendes et al., 2011; Kootbodien et al., 2012; Jassat et al., 2013)

Children experience multiple pesticide exposure scenarios in both urban and rural settings (for example, playing in sprayed fields, applying pesticides, applications of lice shampoos and scabies treatments, petting dipped animals, eating and drinking street pesticides), along with accumulating pesticide exposures from sources such as breast milk, soil, food and water (Rother, 2001). Yet there is a prevailing assumption that pesticide exposures predominantly occur in agricultural areas, resulting in under-reporting and misdiagnosis of cases, particularly from street pesticides (Balme et al., 2010; Rother, 2010). Children's unique vulnerability to pesticides is well established (NRC, 1993; Landrigan, 2001; Goldman et al., 2004). South African studies have found that babies with birth defects are more likely to be born to women exposed to garden and agricultural pesticides, as well as DDT indoor residual spraying (IRS) (Bornman et al., 2010), to women engaged in livestock dipping for ticks, and to women who re-use pesticide containers for collecting water. Levels of DDT and DDE in the breast milk of South African women living in IRS areas for malaria have been shown to be five times the Food and Agricultural Organization's (FAO) defined allowable daily intake (ADI) (Bouwman et al., 2012). Accurate pesticide poisoning statistics for children are lacking in South Africa (London et al., 1994; London, 1998; London & Bailie, 2001) despite pesticide poisoning being a notifiable medical condition (Rother, 2012). Findings from a referral hospital in Cape Town indicate that child pesticide poisoning incidents are on the increase (Balme et al., 2010).

Death, disfigurement and disability from injury occur predominantly in the home setting and disproportionately among children (Bartlett, 2002) and the poor (Baker et al., 1992; Roberts et al., 1998). Despite this, limited attention has been devoted to injury prevention, management and control in developing countries. Data from the year 2000 show that the death rate per 100 000 in South African children aged 0 to 4 years equalled 132, compared with 28 in children aged 5 to 14 years, and 76 for the total South African population (Bradshaw et al., 2003). Road traffic injuries, fires, drowning and poisoning, in which environmental factors are important contributors, accounted for 61 deaths per 100 000 children. The injury-associated death rate is higher among boys relative to girls. In respect of drowning, for example, the death rate in girls equalled 7, compared with 13 per 100 000 in boys. Children may also witness or become victims of inter-personal violence in their homes or communities where violence is endemic (e.g. children caught in the cross-fire of gang warfare in the Western Cape).

5. Looking to the future

The extent of the housing, environmental health infrastructure and services backlog, alongside the political commitment to addressing it, provides an extraordinary opportunity in South Africa to ensure that development and poverty alleviation strategies are geared toward children reaching high levels of health, and their full potential in life (Mathee, 2011). Local and provincial health departments could facilitate this by fostering strong and co-operative working relationships with non-health sectors in which the needs and vulnerabilities of children (and therefore of all society) are included in the development process – that is, children's environmental health in all polices. Partnerships between the Health and Planning sectors were critical in improving the appalling living conditions and poor health status that prevailed in England during the rapid industrialisation era of the nineteenth century (Corburn, 2004), and may now be beneficially applied to avert prevailing and predicted environmental hazards to the health of young children. For example, the predicted epidemic of inactivity, obesity, mental ill health, and vector-borne and chronic diseases in developing countries (Prentice, 2006), may be stemmed by designing and building living environments that promote child safety and physical activity through increasing neighbourhood ‘walkability’, providing infrastructure for active transport (walking and cycling paths), adequate street lighting, sufficient open and play space with child-focused infrastructure, community gardens, shopping facilities within walking distances, access to public transport and so on). Careful consideration of the location of new housing settlements and schools well away from mine tailings dumps, industrial sources of pollution and busy highways constitute a cost-effective and sensible means of preventing environment-related disease and injury.

5.1. Adapting to climate change: Child considerations

The advent of climate change has increased the urgency and import of child-centred development to protect the poorest against the ramifications of more severe and frequent adverse weather events, which is likely to be most detrimental for, and amplify the risks to those living in, settings of poverty and under-development (Sheffield & Landrigan, 2010). In the coming decades for example, South Africa is predicted to experience an increase in temperature that exceeds the global average (Wright et al., 2014b) and currently certain parts of the country are experiencing a severe drought, the child health implications (such as nutrition and dehydration) of which are little understood (Baudoin et al., 2017). Amongst the aspects that the census data do not consider is the impact climate change will have on children's mental health, particularly poor children who experience destruction of homes and communities from fires and floods (UNICEF, 2011). Choices in the design, orientation and materials used in new housing and neighbourhood developments will have a bearing on the capacity of communities (especially children) to adapt to and endure heat waves, storms of increasing intensity and other consequences of climate change. This includes the need for preventative action such as new, more robust standards and guidelines for stormwater drainage, waste removal, low-toxicity pest control, transport, disaster prevention (beyond crisis management) and management plans, and the application of adequate planning principles (such as location of housing beyond flood lines) (Wright et al., 2014a).

6. Conclusion

Two decades of democracy in South Africa have been associated with accelerated housing development and access to basic services, which has been of environmental health benefit to hundreds of thousands of young children. Nevertheless, many South African children continue to live, play and learn in environments that are hazardous to their health and safety, which is often correlated with high rates of poverty and the provinces in which they live (children living in predominantly rural provinces face the highest levels of risk). The likely amplification of environmental health hazards as climate change unfolds will increase the health vulnerability of children, especially the poorest. In this light greater urgency and momentum is needed to improve living conditions and other socio-environmental determinants of children's health in the context of a comprehensive and holistic approach to development. In this regard children should be at the centre of policy decisions and planning as our global society strives to meet the sustainable development goals and its indicators, and particularly the goal of no poverty. Setting environmental health and housing guidelines and standards that use children's needs and vulnerabilities as the benchmark ensures higher levels of environmental health protection, reducing environmental injustices and alleviating poverty for all South Africans. For this to occur, there is an urgent need for scaled-up research towards a finer understanding of the environmental health hazards faced by South African children.

Disclosure statement

No potential conflict of interest was reported by the authors.

Additional information

Funding

This work was supported by South African Medical Research Council: [grant number Baseline Grant 1].

Notes

1 Apartheid was a system of government in place in South Africa from 1948 to 1993, and in terms of which all members of the population were designated to one of four population groups: White; Indian; Coloured; and Black African. Under Apartheid, the minority White population benefitted significantly in terms of political rights, employment, housing, education, environmental rights and health and other services.