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Article

The COVID-19 crisis—the most catastrophic international public health emergency since the Spanish influenza 100 years ago—provides impetus to review the significance of public and global health in the context of Sustainable Development Goal (SDG) achievement. When countries unanimously adopted the 17 SDGs in September 2015, stakeholders had mixed views on global health goal SDG 3 (Good Health and Well-Being). Concern arose over the feasibility of achieving SDG 3 by 2030 when countries pursued its nine targets and four means of implementation with sixteen other ambitious global goals. Nonetheless, health surely cuts across the SDG framework: for instance, the underlying health determinants are expressed in many goals as is urban and planetary health. Although health (and its different constructions) is central to overall SDG achievement, SDG success depends on a paradigm shift toward whole-of-government policy and planning. Indeed, the 2030 Agenda echoes calls for a Health in All Policies (HiAP) approach to public health programming. This depends on another paradigm shift in public health tertiary education, practitioner training, and policy skills development within and beyond ministries of health. Added to this are the underlying problematics around SDG health financing, human resources for health, health target and indicator localization for equitable country responses that leave no one behind, strengthening civil registration and vital statistics systems for inclusive and accountable health implementation, and the sidelining of human rights from SDG metrics. While COVID-19 has derailed SDG efforts, it could also be the ultimate game changer for intergenerational human and environmental health transformation. Yet strong global health governance and rights-based approaches remain key.

Article

Ashley van Niekerk

A burn occurs when cells in the skin or other tissues are destroyed by hot liquids (scalds), hot solids (contact burns), or flames (flame burns). Injuries to the skin or other organic tissue due to radiation, radioactivity, electricity, friction or contact with chemicals are also identified as burns. Globally, burns have been in decline, but are still a major cause of injury, disability, death and disruption in some regions, with about 120,000 deaths and 9 million injuries estimated in 2017. Low-to-middle-income countries carry the bulk of this burden with the majority of all burn injuries occurring in the African and Southeast Asia regions. Thermal injuries are physically painful and may leave disabling scars not only to the skin or the body, but also impair psychological wellbeing. Severe injuries often impose significant psychological, but also educational consequences and social stigmatization, with the consequent adjustments exacerbated by a range of factors, including the circumstances of the burn incident, the severity and site of the injury, the qualities of the affected individual’s personality, and the access to supportive interpersonal and social relationships. The contributions of: economic progress, enhanced environmental and home structures, energy technology, and safety education interventions have been reported as significant for burn prevention. Similarly, legislative and policy frameworks that support access to modern energies such as electricity, govern domestic appliances and heating technology, and control storage and decanting of fossil fuels are important in energy impoverished settings. The recovery of burn survivors is affected by the availability of specialized treatment, physical rehabilitation and psychosocial support to burn victims and families, but which is still limited especially in resource constrained settings.

Article

Most cities in low- and middle-income countries have substantial proportions of their population living in informal settlements—sometimes up to 60% or more. These also house much of the city’s low-income workforce; many informal settlements also concentrate informal economic activities. These settlements usually lack good provision for water, sanitation, and other essential services. The conventional government responses were to bulldoze them or ignore them. But from the 1960s, another approach became common—upgrading settlements to provide missing infrastructure (e.g., water pipes, sewers, drains). In the last 20 years, community-driven upgrading has become increasingly common. Upgrading initiatives are very diverse. At their best, they produce high-quality and healthy living conditions and services that would be expected to greatly reduce illness, injury or disablement, and premature death. But at their worst, upgrading schemes provide a limited range of improvements do nothing to reduce the inhabitants’ exclusion from public services. There is surprisingly little research on upgrading’s impact on health. One reason is the very large number of health determinants at play. Another is the lack of data on informal settlement populations. Much of the innovation in upgrading is in partnerships between local governments and organizations formed by informal settlement residents, including slum/shack dweller federations that are active in over 30 nations. Community-driven processes can deal with issues that are more difficult for professionals to resolve—including mapping and enumerations. Meanwhile, local government can provide the connections to all-weather roads, water mains, sewers, and storm drains into which communities can connect.

Article

Climate change has resulted in rising global average temperatures and an increase in the frequency and intensity of extreme weather events, which already has and will yield serious public health consequences, including the risk of diarrheal diseases. Sufficient evidence in the literature has highlighted the association between different meteorological variables and diarrhea incidence. Both low and high temperatures can increase the incidence of diarrheal disease, and heavy rainfall has also been associated with increased diarrhea cases. Extreme precipitation events and floods are often followed by diarrhea outbreaks. Research has also concluded that drought can concentrate pathogens in water sources, which makes it possible for diarrhea pathogens to distribute broadly when the first heavy rain happens. Substantial evidence underscores the important role social, behavioral, and environmental factors may have for the climate-diarrhea relationship. Meteorological factors may further influence the social vulnerability of populations to diarrhea through a variety of social and behavioral factors. Future research should focus on social factors, population vulnerability, and further understanding of how climate change affects diarrhea to contribute to the development of targeted adaptation strategies.

Article

Raymond Yu Wang and Xiaofeng Liu

Household water use accounts for an important portion of water consumption. Notably, different households may behave differently regarding how water is used in everyday life. Trust and risk perception are two significant psychological factors that influence water use behavior in households. Since trust and risk perception are malleable and subject to construction, they are useful for developing effective demand management strategies and water conservation policies. The concepts of trust and risk perception are multidimensional and interconnected. Risk perception varies across social groups and is often shaped by subjective feelings toward a variety of activities, events, and technologies. Risk perception is also mediated by trust, which involves a positive expectation of an individual, an organization, and/or an institution that derives from complex processes, characteristics, and competence. Likewise, different social groups’ trust in various entities involved in household water use is subject to the significant and far-reaching impact of risk perception. The complexity of the two notions poses challenges to the measurement and exploration of their effects on household water use. In many cases, risk perception and trust can influence people’s acceptance of water sources (e.g., tap water, bottled water, recycled water, and desalinated water) and their conservation behavior (e.g., installing water-saving technologies and reducing water consumption) in household water use. Trust can affect household water use indirectly through its influence on risk perception. Moreover, trust and risk perception in household water use are neither given nor fixed; rather, they are dynamically determined by external, internal, and informational factors. A coherent, stable, transparent, and fair social and institutional structure is conducive to building trust. However, trust and risk perception differ among groups with diverse household and/or individual demographic, economic, social, and cultural characteristics. Direct information from personal experiences and, more importantly, indirect information from one’s social network, as well as from mass media and social media, play an increasingly important role in the formation and evolution of trust and risk perception, bringing a profound impact on household water use in an era of information. Future directions lie in new dynamics of risk perception and trust in the era of information explosion, the coevolution mechanism of risk perception and trust in household water use, the nuanced impacts of different types of risks (e.g., controllable and uncontrollable) on household water use, and the interactive relations of risk perception and trust across geographical contexts.

Article

There is extensive evidence that people with disabilities experience significantly poorer health than their nondisabled peers. These are, in part, health inequities (differences in health status that are avoidable, unjust, and unfair) resulting from increased rates of exposure of people with disabilities to a range of well-established social (and environmental) determinants of poor health, including poverty, reduced access to effective education, lack of employment or employment under hazardous or precarious conditions, social disconnectedness, violence, discrimination, and poor healthcare. They also include environmental determinants of poor health that are a direct result of human activity (e.g., outdoor air pollution resulting from industrial processes and transportation). In addition, people with disabilities are often less likely than their peers to have access to many of the resources (power, wealth, social support, problem-solving skills) that have been linked to increased resilience in the face of adversity. As such, it would appear reasonable to expect that the health of people with disabilities is as likely, if not more so, to deteriorate, when exposed to social determinants, than the health of their nondisabled peers. Future research needs to focus on two key issues. First, given that most of the current evidence has been generated in high-income countries, it is critical for future research to focus on the situation of people with disabilities living in middle- and low-income countries. Second, more needs to be known about the determinants of the resilience and/or vulnerability of people with disabilities. Some significant limitations remain in the current evidence base, but it is clear that existing knowledge is sufficient to drive and guide changes in policy and practice that could reduce the health inequities faced by people with disabilities. These include (a) improving the visibility of people with disabilities in local, national, and international health surveillance systems; (b) making “reasonable accommodations” to the operation of healthcare systems to ensure that people with disabilities are not exposed to systemic discrimination in access to and the quality of healthcare; and (c) ensuring that people with disabilities are included in and benefit equally from local and national strategies to reduce population levels of exposure to well-established social determinants of health.

Article

Water utilities commonly use complex, nonlinear tariff structures to balance multiple tariff objectives. When these tariffs change, how will customers respond? Do customers respond to the marginal volumetric prices embedded in each block, or do they respond to an average price? Because empirical demand estimation relies heavily on the answer to this question, it has been discussed in the water, electricity, and tax literatures for over 50 years. To optimize water consumption in an economically rational way, consumers must have knowledge of the tariff structure and their consumption. The former is challenging because of nonlinear tariffs and inadequate tariff information provided on bills; the latter is challenging because consumption is observed only once and with a lag (at the end of the period of consumption). A large number of empirical studies show that, when asked, consumers have poor knowledge about tariff structures, marginal prices, and (often) their water consumption. Several studies since 2010 have used methods with cleaner causal identification, namely regression discontinuity approaches that exploit natural experiments across changes in kinks in the tariff structure, changes in utility service area borders, changes in billing periods, or a combination. Three studies found clear evidence that consumers respond to average volumetric price. Two studies found evidence that consumers react to marginal prices, although in both studies the change in price may have been especially salient. One study did not explicitly rule out an average price response. Only one study examined responsiveness to average total price, which includes the fixed, nonvolumetric component of the bill. There are five messages for water professionals. First, inattention to complex tariff schedules and marginal prices should not be confused with inattention to all prices: customers do react to changes in prices, and prices should remain an important tool for managing scarcity and increasing economic efficiency. Second, there is substantial evidence that most customers do not understand complex tariffs and likely do not respond to changes in marginal price. Third, most studies have failed to clearly distinguish between average total price and average volumetric price, highlighting the importance of fixed charges in consumer perception. Fourth, evidence as of late 2020 pointed toward consumers’ responding to average volumetric price, but it may be that this simply better approximates average total price than marginal or expected marginal prices; no studies have explicitly tested this. Finally, although information treatments can likely increase customers’ understanding of complex tariffs (and hence marginal price), it is likely a better use of resources to simplify tariffs and pair increased volumetric charges with enhanced customer assistance programs to help poor customers, rather than relying on increasing block tariffs.

Article

Karen Setty and Giuliana Ferrero

Water safety plans (WSPs) represent a holistic risk assessment and management approach covering all steps in the water supply process from the catchment to the consumer. Since 2004, the World Health Organization (WHO) has formally recommended WSPs as a public health intervention to consistently ensure the safety of drinking water. These risk management programs apply to all water supplies in all countries, including small community supplies and large urban systems in both developed and developing settings. As of 2017, more than 90 countries had adopted various permutations of WSPs at different scales, ranging from limited-scale voluntary pilot programs to nationwide implementation mandated by legislative requirements. Tools to support WSP implementation include primary and supplemental manuals in multiple languages, training resources, assessment tools, and some country-specific guidelines and case studies. Systems employing the WSP approach seek to incrementally improve water quality and security by reducing risks and increasing resilience over time. To maintain WSP effectiveness, water supply managers periodically update WSPs to integrate knowledge about prior, existing, and potential future risks. Effectively implemented WSPs may translate to positive health and other impacts. Impact evaluation has centered on a logic model developed by the Centers for Disease Control and Prevention (CDC) as well as WHO-refined indicators that compare water system performance to pre-WSP baseline conditions. Potential benefits of WSPs include improved cost efficiency, water quality, water conservation, regulatory compliance, operational performance, and disease reduction. Available research shows outcomes vary depending on site-specific context, and challenges remain in using WSPs to achieve lasting improvements in water safety. Future directions for WSP development include strengthening and sustaining capacity-building to achieve consistent application and quality, refining evaluation indicators to better reveal linked outcomes (including economic impacts), and incorporating social equity and climate change readiness.

Article

The term “global South” (or just “South” or “south”) refers to the diverse range of countries in Asia, Africa, and Latin America that have a colonial past and are usually characterized by high levels of poverty and informality. The term global South has widely replaced other, similar, terms such as the Third World, developing countries, and low- and middle-income countries. Urbanization, in its narrow sense, refers to an increase in the proportion of the population living in urban areas; in its wider sense it refers to all the social, economic, biophysical, and institutional changes that result from and accompany urban growth, many of which have a profound impact on human health and well-being. The global South is the most rapidly urbanizing part of the world. Since about 2015, more than 75% of the world’s urban population lives in the global South. It is projected that by 2025, the urban population of the global South will be 3.75 billion (54.3% of the total population of the global South). Most of this urbanization is as a result of urban areas having higher natural population growth rates than rural areas, but migration to urban areas also plays a significant role. Although urbanization processes vary considerably across different countries in the global South (e.g., between different regions and between middle-income and low-income countries), there are a number of broad common trends: a rapid increase in the number of megacities (urban agglomerations with a population of more than 10 million), ongoing strong urban–rural linkages and increased blurring of “urban” and “rural,” increased urban sprawl and fragmentation, and growing intra-urban inequalities. There has been much debate about the nature of cities and urban life in the global South, giving rise to a body of literature on “southern urbanism,” characterized by case studies of everyday life. Urbanization processes in the global South have contributed to the growth and complexity of the burden of disease. Infectious diseases have continued at high levels due to poor environmental conditions in many parts of cities, particularly in informal settlements and other types of slums. Noncommunicable diseases are also growing rapidly in the global South, linked to changes in living conditions and lifestyle associated with urbanization. It is anticipated that the burden of disease in cities of the global South will continue to increase as urbanization continues, as a result of increased traffic injuries and respiratory disease resulting from increased numbers of motor vehicles; growing levels of violence due to growing levels of poverty and inequality in many cities; growing obesity as a result of changed lifestyles associated with urbanization; growing numbers of unsafe settlements in hazardous areas; and a high risk of infectious diseases. Climate change is likely to exacerbate these risks.

Article

Organizations regulating the water sector have major impacts on public health and the sustainability of supply to households, industry, power generation, agriculture, and the environment. Access to affordable water is a human right, but it is costly to produce, as is wastewater treatment. Capital investments required for water supply and sanitation are substantial, and operating costs are significant as well. That means that there are trade-offs among access, affordability, and cost recovery. Political leaders prioritize goals and implement policy through a number of organizations: government ministries, municipalities, sector regulators, health agencies, and environmental regulators. The economic regulators of the water sector set targets and quality standards for water operators and determine prices that promote the financial sustainability of those operators. Their decisions affect drinking water safety and sanitation. In developing countries with large rural populations, centralized water networks may not be feasible. Sector regulators often oversee how local organizations ensure water supply to citizens and address wastewater transport, treatment, and disposal, including non-networked sanitation systems. Both rural and urban situations present challenges for sector regulators. The theoretical rationale for water-sector regulation address operator monopoly power (restricting output) and transparency, so customers have information regarding service quality and operator efficiency. Externalities (like pollution) are especially problematic in the water sector. In addition, water and sanitation enhance community health and personal dignity: they promote cohesion within a community. Regulatory systems attempt to address those issues. Of course, government intervention can actually be problematic if short-term political objectives dominate public policy or rules are established to benefit politically powerful groups. In such situations, the fair and efficient provision of water and sanitation services is not given priority. Note that the governance of economic regulators (their organizational design, values or principles, functions, and processes) creates incentives (and disincentives) for operators to improve performance. Related ministries that provide oversight of the environment, health and safety, urban and housing issues, and water resource management also influence the long-term sustainability of the water sector and associated health impacts. Ministries formulate public policy for those areas under their jurisdiction and monitor its implementation by designated authorities. Ideally, water-sector regulators are somewhat insulated from day-to-day political pressures and have the expertise (and authority) to implement public policy and address emerging sector issues. Many health issues related to water are caused or aggravated by lack of clean water supply or lack of effective sanitation. These problems can be attributed to lack of access or to lack of quality supplied if there is access. The economic regulation of utilities has an effect on public health through the setting of quality standards for water supply and sanitation, the incentives provided for productive efficiency (encouraging least-cost provision of quality services), setting tariffs to provide cash flows to fund supply and network expansion, and providing incentives and monitoring so that investments translate into system expansion and better quality service. Thus, although water-sector regulators tend not to focus directly on health outcomes, their regulatory decisions determine access to safe water and sanitation.