V. Furman, Ph.D. (EHC), N.Lebedeva, MD, (EHC),
A.Biran, Ph.D. (LSHTM)
Childhood Environmental
Health Concerns in Russia.
V. Furman,
Ph.D. (EHC), N.Lebedeva, MD, (EHC), A.Biran, Ph.D. (LSHTM)
Introduction
Environmental
Health Centre is one of the few Russian organisations, which is
responsible for the development of environmental epidemiology and health risk
assessment methodologies in Russia. Being a WELL resource centre network
partner we considered the possibilities for environmental interventions to address
major causes of child mortality and morbidity and environmental health concerns
in Russia. It was based on the results of the preliminary scoping studies
carried out by our Centre during May – October 2002. The scoping studies
themselves were based on published and unpublished literature and on
discussions with key stakeholders. Each of the scoping studies concluded with
initial recommendations for further priorities in work for the next decadefour years.
The most important thing for us was the identification of environmental health
problems, which are meaningful but not under proper consideration in
responsible agencies or organisations in our country and assessment of the
possibilities for environmental interventions to address those problems.
Findings of the scoping study
As a
result of analysis of a number of national and regional acts, statements,
reports and other documents a wide spectrum of environmental health problems in
the Russian federation was were identified.
These included the microbiological and chemical contamination of drinking water
and food products, ambient and indoor air pollution, traffic and industrial
accidents and radioactive pollution in specific regions. Discussions with a
number of stakeholders reaffirmed the perceived importance of these problems. H however, prioritising these concerns,
both for the whole of Russia and for different regions within the country, is
difficult. Not only are there few professionals with training in environmental
epidemiology, and health risk assessment, but the
data available at local and regional levels are is thought
to be unreliable, and raw, primary data are is not
accessible to allow verification.
There
is still a very high level of maternal and infant mortality in Russia. Two
years ago at the House hearings it was recognized that the state policy in the
field of protection of maternal and child health was ineffective. There has
been a rise in alcohol and drug abuse, leading to
an increase in children with mental disorders. Disorders of reproductive
functions of women and an increase in morbidity among pregnant women has caused
a decrease in normal deliveries and an increase in a the number
of prematurely born children.
The
proportion of child mortality in Russia attributed to different causes slightly varies slightly between
regions. However, the relative importance attributed to different causes
remains consistent. Acute respiratory infections emerge as the leading cause of
deaths in the 0 to1 year age group, followed by diarrhoeal disease and
congenital abnormalities, appearing in the perinatal
period.
Infant
mortality has stagnated during the last 5 years in the Russian Federation at
around 18 deaths per 1000 live births.
In a regional aspect the level of infant mortality is 25% higher in 12
regions of the Russian Federation, which are considered environmentally unsafe
in comparison with the other environmentally favorable regions. Nevertheless it
is considered that the major cause of high level of deaths among infants is an
ineffective public health service especially as a result of poor intranatal and
perinatal medical assistance. Almost all stakeholders whom we interviewed
during the scoping study confirmed it.
There
are few publications and little research related to the causes of mortality in
children aged 1-4 years, however accidental poisoning, drowning and other
accidents are suggested to be a major cause of childhood mortality in Russia. The National
Environmental Health Action Plan (NEHAP) (Ministry of Health. M., 2001) also suggests a rank order
of priority for environmental health problems. As causes of mortality, traffic
accidents and ambient air pollution are ranked highest, with 30,000 and 22,000
attributed deaths annually. The two leading causes of morbidity listed are microbiological
contamination of water and food products, and ambient air pollution. The first
of these is thought to result in over 400,000 cases of gastro-intestinal
infections annually, and the second between 240,000 and 370,000 cases of
respiratory disease annually.
Accidents
and injuries are a significant component of the ‘other’ causes of childhood
mortality. Childhood accidents and injuries is an area in which there may be
potential for environmental interventions, but about which knowledge is limited.
One PhD thesis on causes of death in a Russian city reports 23.9% of childhood
deaths from accidents, poisonings, traumas and burns (Korchagina 1997). The
poor suffered the highest
rates of childhood deaths. The Federal Programme of Scientific Research and
Engineering Works (2001) recognises that child mortality is generally worse in
rural areas, and is highest amongst the indigenous populations of the far north
of the country. Here it is reported to be 1.7 times the national average.
The
feeling amongst the stakeholders consulted is that,
the state is more inclined to take an interest in the
problems of infant and maternal mortality, but tends to regard the health of
children from the age of 1 year as the responsibility of individual families.
There are a number of regions in the Russian Federation, where the situation with drinking
water is not satisfactory and regional programmes on the improvement of water
supply systems and quality of drinking water are currently under way. In Russia
27,.9%
of public and 40.,4%
of industrial water supply systems till now have incomplete treatment systems
and 12.,3% and 28.,3% correspondingly do not have
disinfection.
In rural areas 78% of water
supply systems are using underground water, most of them are obsolete and
supply water of poor quality. 23% of
all decentralized water supply sources do not meet sanitary standards. There is
a strong tendency of growth of outbreaks of waterborne gastro-intestinal
diseases (112 in 1997 to 168 in 2000). [State report on “Sanitary and
epidemiology situation in the Russian Federation in the year of 2000”, 2001]
There
are two main agencies responsible for the provision of safe drinking water in
Russia. These are Gossanepidnadzor and Vodocanal. Gossanepidnadzor is
responsible for monitoring drinking water quality at the tap and Vodocanal is
responsible for water treatment facilities and within the distribution system.
The patterns and relative importance of chemical and microbiological pollution
of drinking water vary across the different regions of Russia. Lessast is known about microbiological
pollution. Cryptosporidium has recently been recognised as one of the causes of
the gastro-intestinal infections
associated with drinking water quality in Russia (Ford et al,
1999), and has been found in samples from the water supplies of a number of
cities. However, the scale of this problem is not known. The secondary
contamination of water and re-growth of pathogens within the distribution
systems is also thought to be a problem. Concern is growing over the health
risks posed by the by-products of disinfection. These are
frequently found at concentrations in excess of the standards used in the
United States. Several of these by-products are believed to be
associated with cancers, birth defects and spontaneous abortions.
A
number of federal programmemes and legislative acts exist with the aim
of improving the health of children. For example clause 28 of the Federal Act
About Sanitary and Epidemiological Well-being of the Population, adopted by the
sate Duma on March 12th 1999, states that in all schools and
kindergartens there should be programmesprogrammes of preventive health care and health
promotion.
In
order to begin to address the environmental health problems identified, NEHAP
includes research and the development and implementation of guidelines in a
number of areas. These include:
·
Identifying the hazards and exposures
associated with polluted air and drinking water.
·
Standardising the methods of collection and
analysis of pollutants.
·
Identifying the priority pollutants in drinking
water and assessing their impact on population health.
·
Studying particulate pollution in cities with
different types of industry and different climates.
·
Developing guidelines and expertise for the use
of health risk assessment for environmental hazards and the risks posed by
drinking water quality.
·
Studying the health impact of disinfectant by -products
in drinking water.
Particular
attention is also given to the need to train environmental health specialists
in environmental epidemiology and health risk assessment for priority setting
in decision making.
A
lack of funding means that many government actions have amounted to
declarations of intention rather than actual programmes of work. There is
however, at least on paper, a commitment by the state to improving the health
of nation and children especially.
ConclusionsProposals to
address the concerns
The
health of children, in contrast to that of infants, appears to be a largely
neglected area in Russia, and the environmental influences on children’s health
in particular has received little attention.
·
Register of
child accidents and traumas
Drowning,
poisoning and other accidents emerge as important causes of childhood deaths in
Russia. However, little information is available on the causes or epidemiology
of accidental childhood deaths in the country. The primary data on the causes
of accidents are collected in local and regional hospitals and clinics. There
is no centralised database. The value of developing a register of child
accidents and traumas has been recognised and discussed within the Ministry of
Health, but no practical action has been taken. An information and reporting
system could to be developed as a first step to
understanding and addressing these causes of death.
The
Ministry of Health of the Russian Federation, the Scientific
Research Institute of hygiene of children and teenagers of the Scientific
Centre of children health, and the Russian Academy of Medical Sciences (director, professor V. Kuchma) are
interested in the development of a register of accidents, poisonings and
traumas of children. The development of this register could be justified under
a statement of the Federal Government (Federal Government,
2001).
·
Reporting and
information system
EHC has proposed
to help develop a reporting and information system for childhood accidents in
Russia. This would be done in collaboration with the Ministry of Health, local
and regional hospital staff and other stakeholders.
In
order for this work to progress in collaboration with key stakeholders in
Russia, it will be necessary to write a detailed protocol setting out the
scope, process, outcomes and timeframe for the work. The development of this
protocol would be a useful process in itself. A first step in this process
would be to review existing systems operating in other countries and to prepare
a short proposal to share with key stakeholders in Russia.
·
Water Safety
Plans
Drinking
water quality in Russia is clearly a matter of concern. The risk -based
approach to setting targets for drinking water quality, and the management of
drinking water supply based around a Water Safety Plan -, as proposed by WHO in the draft
water quality guidelines for 2003 - are of interest to the Ministry of Health.
WHO has also expressed an interest in seeing this approach developed for use in
the Russian region. This approach would also allow the risks associated with
disinfection by-products in drinking water to be considered in a balanced
framework and compared with the risks posed by microbiological contamination.
It
might be desirable to pilot the approach in one of the major cities. However,
at present little is known in Russia about the concept of Water Safety Plans,
and the use of quantitative risk assessment is not accepted as valid by all
stakeholders. A useful and important first step would therefore be to review
existing materials relating to drinking water quality and Water Safety Plans
and to summarise current thinking on the subject for key stakeholders in
Russia.
·
Dissemination
and training
Dissemination could take the form of a short concept note in Russian and
a preliminary workshop with stakeholders at which these ideas could be
presented and discussed.
There
is a great need for training of Russian professionals in environmental
epidemiology, health risk assessment and statistical methods in order to
improve decision making in environmental health. With this in mind, the
teaching and guidance materials currently available in Russia and abroad could
be reviewed. Following this, in consultation with Russian institutions such as
the Gossanepidnazor and the Environmental Protection Committees, the existing
materials could be revised or new materials written. These materials could then
contribute to short taught courses for professionals from interested agencies.
References
·
Federal Government (2001)
Federal Government Statement of December 29 2001, N916, About a nation wide
system for monitoring population health and the physical development of
children, teenagers and youth.
·
Federal Programme of
Scientific Research and Engineering Works (2001) Children of Russia 2001-2002.
·
Ford, T.,
Egorov, A., Rakitin, P., Segedevich, I., Vasilyeva, M., Kislitsin, V.,
Zemlianaia, G., Fourman, V., Tereschenko, A., Petrova, L., Drizhid, N., (1999)
Assessment of Health Risk Associated with Drinking Water Quality in Russia. Epidemiology, 10 (4) suppl. July, 108O.
·
Korchagina, A. (1997)
Dynamics and causes of mortality in children aged 0-4 years in a large
industrial centre. Unpublished PhD Thesis.
National Report on the status of population health
(2002). Public
Health in the Russian Federation NI 2002
Ford, T., Egorov, A., Rakitin, P., Segedevich, I.,
Vasilyeva, M., Kislitsin, V., Zemlianaia, G., Fourman, V., Tereschenko, A., Petrova,
L., Drizhid, N., (1999) Assessment of Health Risk Associated with Drinking
Water Quality in Russia. Epidemiology, 10 (4) suppl. July, 108O.
·
Ministry of Health (2001)
National Environmental Health Action Plan. Ministry of Health, Moscow.
·
Ministry of Health (2001)
State report on “Sanitary and epidemiology situation in the Russian Federation
in the year of 2000”, M. 2001.
·
National
Report on the status of population health (2002). Public Health in the Russian Federation NI 2002