The price of progress: environmental health in Latin America.

From Tierra del Fuego to the Rio Grande, Latin America's more than 400 million people face enormous challenges. Not only must the region develop economically to improve living standards, it must do so against a backdrop of serious environmental and health problems. The region is beset with difficulties including malnutrition, overpopulation, air pollution, poor or nonexistent sanitation, high disease rates, and a desperate need to improve the supply of potable water. Compounding such problems is political instability that can threaten the ability of the region's governments to improve environmental health. Yet, in a region as large and diverse as Latin America, generalizations are difficult. The 20 nations that make up Latin America do not lend themselves to blanket characterizations. Poor people in countries like Chile and Costa Rica are pretty well off nutritionally, compared to those in countries like Guatemala and Honduras, says Jean-Pierre Habicht, a professor of nutritional epidemiology at Cornell University. Habicht has studied nutrition and malnutrition in Latin America and other regions of the world for three decades. Other health indicators like infant mortality and life expectancy also vary widely across the region. For instance, in Chile infant mortality is 20 per 1,000, while in Bolivia it is 110 per 1,000, according to United Nations' figures. Life expectancy in the two countries also contrasts dramatically: 71 years in Chile versus 53 years in Bolivia. Cash-strapped governments have to face influxes of rural masses into cities as a result of poverty in the countryside, according to political scientist Philip Meeks of Creighton University. "Every country in Latin America has the problem of rural exodus into cities, and then the inability of government to be able to handle demand for social services and public services directly related to the quality of life. The government cannot build enough sewers to handle these favellas [slums] that grow up around the cites," he says. Even a country as prosperous as Argentina suffers from this problem, according to Gettysburg College economist Eileen Stillwaggon, who is writing a book on the impact of poor primary health care on the Argentine economy. "There's no income to be made in the Philip Mee countryside. So [people come to Latin America the city] where they live in things relate wretched slums in the periphery typically igno of Buenos Aires. Like elsewhere in the world they're crowding into periurban slums," she says.


Water Problems Everywhere
Running throughout many of the environmental problems faced by Latin America is a common denominator: the lack of clean water for drinking. Wastewater treatment plants and sewers are often not working or nonexistent.
For example, only a small percentage of metropolitan Buenos Aires is served by a sewage system. So the rest of the sewage goes into cesspools that may not be properly constructed. Says Stillwaggon, "The sewage system itself hasn't been working for a number of years, and so what goes into the sewers leaks out in to the streets because of breaks in r Dksan c d tc red.
Water into waste. In Port-au-Prince, Haiti, the water supply has become a garbage dump. the mains, or it's dumped directly into the River Plate because the treatment plants are broken." Mexico City offers another example. "Ninety-five percent of the industrial and domestic sewage is untreated. It flows through the city in an open canal," says Diane Perry of the University of California at Los Angeles. Perry, a research biologist D who directs international programs at UCLA's Center of -Occupational and Environ-°m ental Health, says it appears cn that some of the industrial compounds from this sewage are seeping into the aquifer that provides drinking water for the city's 20 million-plus inhabitants. "No one knows for sure, she says, "but there's a suspicion there could be contamina--In many tion." Such conditions provide :ountries, all fertile ground for disease, 3 health are according to Raymond Reid, regional advisor for water supply at the Pan American Health Organization (PAHO). "Cholera was reintroduced into Latin America in 1991. This was not expected, but it's one of the consequences of inadequate disposal of sewage," he says.
Diseases like yellow fever and dengue, which are resurgent in Latin America, also result from inadequate treatment of sewage, which provides the breeding ground for the Aedes aegypti mosquito, the carrier of these viral diseases. "It's such an adaptable mosquito-living in water containers in and around human habitations-that it's come back as a very serious problem," says Thomas Yuill, an infectious disease specialist at the University ofWisconsin in Madison Malaria is also coming back. "There are one million new cases of malaria in this region every year," says Horst Otterstetter, director of the Division of Health and Environment at PAHO. "A considerable amount of these problems stems from poor environmental conditions: poor sanitation, poor drainage, poor waste collection, all this serving as a breeding ground for these mosquitoes. The accumulation of water in all these poorly planned and poorly maintained urban areas is one of the reasons why these diseases are coming back to these cities." According to PAHO, less than 10% of the municipalities in Latin America treat sewage adequately before emptying it into natural watercourses. Ninety percent of the water is dumped into the rivers without any treatment, and these rivers function as water sources for cities downstream. The loss of quality is a constant factor throughout Latin America and "since the investments over the last 10 years were very small," says Otterstetter, "over the last 10 years this situa- tion has worsened." Furthermore, PAHO the [systems] they did put in in the 1970s finds that South America pollutes nearly 11 and 1980s ... is now deteriorating because times more freshwater on a per capita basis they can't even afford to bring in the capital than Europe. "Managing and treating urban to do the maintenance. All the things related wastewater is one of the major challenges to health are typically ignored, or the maintethat countries have to face in the coming nance is not done," says Meeks. years," states a PAHO review of environmental conditions in the region.

Too Many People, Not Enough
In 1980 the United Nations General Resources Assembly launched the International While confronting deteriorating water infra-Drinking Water Supply and Sanitation structure, Latin American governments also Decade with the goal of providing an adequate and safe water supply and sanitation to the world's people. According to PAHO, the effort in Latin America has fallen short of expectations. The goal of providing a safe water supply for 91% of city dwellers was not reached, nor was the goal of making sewage connections available for 71% of city residents. must try to rein their burgeoning populations. The growth of population in the region is a serious problem, one that is likely to continue for the next two decades, according to Cornell University sociologist Joseph Stycos, an authority on population growth in Latin America. The increasing numbers of people, he says, strain the capacity of governments to cope. "It exacerbates every other social and economic problem. If the government is trying to put in more school seats, On the other hand, the decade helped countries to recognize that they must come to grips with the challenge of providing safe water to their people. Yet this awareness comes up against the reality of water supply systems that deteriorated badly during the 1980s. "The countries established priorities which were in areas other than water supply and sanitation," says Otterstetter.
One of those priorities was paying off debt brought about by increased oil prices.
"Most of these countries got themselves into tremendous debt. They're paying more to service their debt than they can get in new A not-so-slow leak. Drums of hazardous waste already leak their contents into soil and water in a new capital to keep up. So the maintenance on waste facility in Baja. I 9Oly l "E i Living on the edge. In some areas of Peru, slums are built directly on the water supplies, which soon become contaminated.
they're rapidly taken up by the population increase. If the government is trying to provide new jobs, those jobs are overwhelmed by the increase of aspirants," says Stycos.
According to Meeks, "There is no question that the governments can't keep up with the population growth. With their growth anywhere between two and three percent a year, their economies have to grow more than advanced industrial economies ... they have to grow between five and six percent to be able to provide any meaningful improvement.
The growth of population is most serious in Central America, says Stycos. According to figures compiled by the World Resources Institute in Washington, DC, Honduras' population is growing at a 3.18% rate; Nicaragua's at 3.36%, the highest in Central and South America. Guatemala's growth rate is 2.88%, the second highest of any South American country.
The growth rates in Central America are high because of a combination of factors. "They started at a higher rate [than South American countries] because of very early marriage," said Stycos. "Most countries have large indigenous populations and that seems to have made progress more difficult because of ethnic differences and lower educational levels." Typically, higher education levels are linked to lower population growth rates. Chile and Argentina, with their higher overall education levels and heavy European influence, have strikingly low population growth rates compared to the rest of the region. Costa Rica's growth rate is also quite low because of a strong family planning program, says Stycos.
Typical family size has shrunk from six to four, but the problem now, says Stycos, is to get family size to drop from an average of four children to two. "But the effort it's going to take from going from four children to two is much greater than it was to go from six to four. Going from six to four was a question of providing sufficient means, the technology to let women realize the number of children they wanted. But they want around three or four. You've got to change people's minds, and that's a difficult proposition," says Stycos.
In Mexico, one nongovernmental organization working to provide family planning information to hard-to-reach rural areas is FEMAP, a Spanish acronym for Mexican Federation of Private Health and Community Development Associations. It has 44 centers throughout the country. "We provide information on family planning, and we have an education program all over Mexico. We have over 323,000 couples using modern contraceptive methods," says executive director Enrique Suarez. That compares with 3,000,000 couples who are getting contraceptive help from the Mexican government. Suarez adds that FEMAP is reaching over 4,000,000 people a year with information.

Not Enough Nourishment
Malnutrition is another specter haunting much of Latin America. Between one in four and one in five children suffer from chronic malnutrition, according Aaron Lechtig, UNICEF senior regional advisor for health and nutrition in Latin America. He says that figure compares favorably to other regions such as South Asia, where two thirds of the children are malnourished, and Africa, where the figure is 49%.
Though he says the chronic malnutrition rate in Latin America is the lowest in the developing world, Lechtig acknowledges there are wide variations. In Guatemala the rate is 68%, while in Costa Rica it is 8%, and in Chile it is 10%. "Chronic malnutrition has long-term impacts on the productivity on the individual and family level. [It hurts] mental development and this is reflected later in [lowered] per capita income," says Lechtig.
And malnutrition also has more immediate effects, Habicht has found. Although malnutrition doesn't increase the incidence of disease, the effects of diseases that do strike are more severe. Malnourished individuals are much more likely to die when they are sick. "There's a synergism between malnutrition and infection," Habicht says.
In Argentina, doctors at some modern Environmental Health Perspectives 9 9 ;1 E|If children's hospitals have said that 35% of the children they treat are malnourished, according to Stillwaggon. When released from the hospital, she writes, the children "go home to the same inadequate food, contaminated water, crowded unsanitary conditions . . . that sent them to the hospital." What should be done, Lechtig says, is a broad approach not only to make sure people have access to good health care and clean water, but also "helping people to develop their own capacity to analyze their problems and come out with decisions. A very important implication is that those who suffer the problem are also actors in the solution, not just passive recipients of [aid]. This is not a short process, but in the end it will be a sustainable one."

Clearing the Air
Urban air pollution is another source of serious environmental health problems in many Latin American cities. The region is the most urbanized in the developing world, with over 340 million people living in cities.
Isabelle Romieu of PAHO notes that a number of factors contribute to the problem. Writing in the September 1991 Journal of Air and Waste Management, she and her colleagues point to rapid industrialization in Latin American cities, "which was not always well-planned in terms of the protection of the environment." The debt crisis of the 1970s and 1980s also compounded the problem, leaving attempts to control pollution to compete with other priorities.
Accompanying the growth of industry has been a boom in the number of cars, trucks, and buses in cities. For example, according to Romieu, between 1975 and 1984 the number of vehicles in Venezuela, Chile, Colombia, and Mexico more than doubled, with the great majority concentrated in cities.
Attempts at controlling pollution appear to be erratic, with standards often exceeded, according to Romieu, who says that only seven countries-Brazil, Chile, Colombia, Ecuador, Peru, Mexico, and Venezuelahave air quality standards. Although the standards are similar to those in the United States, enforcement is often haphazard.
Aaron Lechtig- The 20 million residents tant that thos of Mexico City and those in the problem ar other major Latin American in the solution. metropolises must breathe air laced with contaminants such as lead, particulates, ozone, and sulfur dioxide. Lead can impair development and intelligence in young children. Ozone can hamper breathing, particularly in young children and the elderly. Microscopic particulates from combustion of diesel fuel, leaded gasoline, and coal can also cause lung damage and have been linked to deaths. Sao Paulo, Santiago, and Bogota, along with Mexico City, face serious problems with particulates.
The overall health effects of such pollution are uncertain because of the lack of accurate measures of exposure and adequate control groups. Horst Ottersti Yet 30 million children and 4 are one million million elderly people in Latin malaria in La America, the people most sen-every year. sitive to the harm that can be done by air pollution "are exposed to air pollutant levels that exceed WHO guidelines for adequate health protection," writes Romieu. She adds that it's important not only to learn ,, what the direct effects of air polz lutants are on human health, but to discover how they may also magnify the health problems caused by malnutrition. There has been some progress, however. In Cubatao, an industrial coastal city approximately 40 miles from Sao Paulo, emissions controls and restrictions on new industries have cut air pollution. In 1988 the efforts is impor-have reduced air pollutants by rho suffer approximately half a million iso actors pounds per day, according to data cited by Romieu.
In Mexico City, the use of unleaded gasoline has reduced the amount of lead in the air. Unleaded gas has paved the way for the use of catalytic converters to control other emissions from cars. "Catalytic converters were introduced in Mexico City in 1991," says Pablo Cicero-Fernandez, an air pollution specialist with the California Air Resources Board, who has studied air pollution problems in Mexico City. "We have also seen a reduction in the concentration of sulfur dioxide in the air of Mexico City, and this is very likely the result of the reduction of sulfur in diesel fuel for buses as well as the use of lowsulfur fuel oil in industry and in some cases the substitution of r-There natural gas in the electric-gener-N cases of ating plants. Air pollution in Am eric a terms of lead and sulfur dioxide is getting better," he says.

Pesticide Problems
Another rural problem is the use of pesticides. "The fact that farmers get no guidance from agricultural authorities or from those who sell agricultural chemicals contributes to the unsafe use of these substances," according to a 1990 PAHO report. PAHO surveys of Guatemala and Costa Rica in the 1980s have turned up hundreds of cases of pesticide poisoning annually. "There's a real need for environmental education in the use and handling of pesticides," says Richard Kiy, the former U.S. acting environmental attache in Mexico.
"In Baja, in some of the vegetable areas south of the border, you can see people applying pesticides without any protective clothing; you can see people mixing things occasionally mixing things with their hands," says Kansas State University sociologist Scott Frey, who has studied pesticide use in the developing world. 3L, 15 Li SS | 35Si the lack of implementation," says Maritza Tennassee, the regional advisor on worker health at PAHO. Consequently, Latin American workers suffer between five and eight times more occupational accidents and illnesses than their counterparts in developed countries. Tennassee also blames a lack of knowledge and a lack of political power for the failure to better protect workers. She says that relatively few workers belong to labor unions, which usually work to protect employee health. Furthermore, unions in Latin