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Concerns about water affordability have centered on access to networked services in low-income countries, but have grown in high-income countries as water, sewer, and stormwater tariffs, which fund replacement of aging infrastructure and management of demand, have risen. The political context includes a UN-recognized human right to water and a set of Sustainable Development Goals that explicitly reference affordable services in water, sanitation, and other sectors. Affordability has traditionally been measured as the ratio of combined water and sewer bills divided by total income or expenditures. Subjective decisions are then made about what constitutes an “affordable” ratio, and the fraction paying more than this is calculated. This measurement approach typically omits the coping costs associated with poor supply, notably the time costs of carrying water home. Three less commonly used approaches include calculating (a) the expenditure related to procuring a “lifeline” quantity of water as a percent of income or expenditures, (b) the amount of income left for other needs after water and sewer expenditures are subtracted, and (c) the number of hours of minimum wage work needed to purchase an essential quantity of water. Lowering water rates for all customers does not necessarily help those in need in low- and middle-income countries. This includes tariff structures that subsidize the price of water in the lowest block or tier (i.e., lifeline blocks) for all customers, not just the poor. Affordability programs that do not operate through tariffs can be characterized by (a) how they are administered and funded, (b) how they target the poor, and (c) how they deliver subsidies to the poor. Common types of delivery mechanisms include subsidizing public taps for unconnected households, subsidizing or financing the fees associated with obtaining a connection to the piped network, and subsidizing monthly bills for poor households. Means-tested consumption subsidies are most common in industrialized countries, whereas subsidizing public taps and connection fees are more common in low- and middle-income countries. A final challenge is directing subsidies to renters who are more likely to be poor and who do not have a direct relationship with a water utility because they pay for water through their landlord, either included as part of their rent or as a separate water payment. Based on data from the 2013 American Housing Survey, approximately 21% of all housing units in the United States are occupied by this type of “hard to reach” customer, although not all of them would be considered poor or eligible for an assistance program. This ratio is as high as 74% of all housing units in metropolitan areas like New York City. Because of data limitations, there are no similar estimates in low-income countries. Instead of sector-by-sector affordability policies, governments might do better to think about the entire package of services a poor person has a perceived right to consume. Direct income support, calculated to cover a package of basic services, could then be delivered to the poor, preserving their autonomy to make spending decisions and preserving the appropriate signals about resource scarcity.

Article

Unconventional natural gas development (UNGD), which includes the processes of horizontal drilling and hydraulic fracturing to extract natural gas from unconventional reservoirs such as shale, has dramatically expanded since 2000. In parallel, concern over environmental and community impacts has increased along with the threats they pose for health. Shale gas reservoirs are present on all continents, but only a small proportion of global reserves has been extracted through 2016. Natural gas production from UNGD is highest in the United States in Pennsylvania, Texas, Louisiana, Oklahoma, and Arkansas. But unconventional production is also in practice elsewhere, including in eighteen other U.S. states, Canada, and China. Given the rapid development of the industry coupled with its likelihood of further growth and public concern about potential cumulative and long-term environmental and health impacts, it is important to review what is currently known about these topics. The environmental impacts from UNGD include chemical, physical, and psychosocial hazards as well as more general community impacts. Chemical hazards commonly include detection of chemical odors; volatile organic compounds (including BTEX chemicals [benzene, toluene, ethylbenzene, and xylene], and several that have been implicated in endocrine disruption) in air, soil, and surface and groundwater; particulate matter, ozone, and oxides of nitrogen (NOx) in air; and inorganic compounds, including heavy metals, in soil and water, particularly near wastewater disposal sites. Physical hazards include noise, light, vibration, and ionizing radiation (including technologically enhanced naturally occurring radioactive materials [TENORMs] in air and water), which can affect health directly or through stress pathways. Psychosocial hazards can also operate through stress pathways and include exposure to increases in traffic accidents, heavy truck traffic, transient workforces, rapid industrialization of previously rural areas, increased crime rates, and changes in employment opportunities as well as land and home values. In addition, the deep-well injection of wastewater from UNGD has been associated with increased seismic activity. These environmental and community impacts have generated considerable concern about potential health effects and corresponding political debate over whether UNGD should be promoted, regulated, or banned. For several years after the expansion of the industry, there were no well-designed, population-based studies that objectively measured UNGD activity or associated exposures in relation to health outcomes. This delay is inherent after the introduction of new industries, but hundreds of thousands of wells were drilled before any health studies were completed. By 2017, there were a number of important, peer-reviewed studies published in the scientific literature that raised concern about potential ongoing health impacts. These studies have reported associations between proximity to UNGD and pregnancy and birth outcomes; migraine headache, chronic rhinosinusitis, severe fatigue, and other symptoms; asthma exacerbations; and psychological and stress-related concerns. Beyond its direct health impacts, UNGD may be substantially contributing to climate change (due to fugitive emissions of methane, a powerful greenhouse gas), which has further health impacts. Certain health outcomes, such as cancer and neurodegenerative diseases, cannot yet be studied because insufficient time has passed in most regions since the expansion of UNGD to allow for latency considerations. With the potential for tens of thousands of additional wells across large geographic areas, these early health studies should give pause about whether and how UNGD should proceed. Citing health concerns, several U.S. states and nations in Europe have already decided to not allow UNGD.

Article

Luiz Augusto Cassanha Galvao, Volney Câmara, and Daniel Buss

The relationship between environment and health is part of the history of medicine and has always been important to any study of human health and to public-health interventions. In Latin America many health improvements are related to environmental interventions, such as the provision of better water and sanitation services. Latin America’s development, industrialization, and sweeping urbanization have brought many improvements to the well-being of its populations; they have also inaugurated new societies, with new patterns of consumption. The region’s basic environmental-health interventions have needed to be updated and upgraded to include disciplines such as toxicology, environmental epidemiology, environmental engineering, and many others. Multidisciplinary and inter-sector approaches are paramount to understanding new profiles of health and well-being, and to promoting effective public-health interventions. The new social, economic, labor, and consumption aspects of modern Latin American society have become more and more relevant to understanding the complex interactions in the region’s social, biological, and physical environment, which are essential to explaining some of the emerging and re-emerging public-health problems. Environmental health, as concept and as intervention, is simple and easily understood, but no longer sufficient to achieve the levels of health and well-being expected and required by these new realities. Many global changes such as climate change, biodiversity loss, and mass migrations has been identified as main cause of ill health and are at the center of the sustainable development challenges in general, and many are critical and specific public health. To face this development, other frameworks have emerged, such as planetary health and environmental and social determinants of health. Public health remains central to some, such as the improved environmental-health agenda, while others assign public health a relative position in a variety of overarching frameworks.

Article

Emily Q. Ahonen, Sherry L. Baron, Lisa M. Brosseau, and Alejandra Vives

Standard employment arrangements—where the relationship between employers and employees is clear and employment is full-time, understood to be lasting, and with full protections—coexist with nonstandard employment (NSE) relationships. A variety of terms have been used to describe specific types of NSE including temporary, contingent, contract, freelance, on-call, gig, and app-based employment. These forms of employment, in combination with larger social and economic forces, structural power dynamics, and advances in technology, can work together to limit the ways in which employment supports health, and undermine workplace health protections. Nonstandard employment brings with it particular concerns for health and safety related to work, and in a broader public health sense. Health can be protected in NSE through intervention at national, state and province, and local levels to proactively shape the quality of employment arrangements.

Article

Climate change has increased the risk to workers’ health and safety. Workers, especially those who work outdoors or in hot indoor environments, are at increased risk of heat stress and other heat-related disorders, occupational injuries, and reduced productivity at work. A variety of approaches have been developed to measure and assess workers’ occupational heat exposure and the risk of heat-related disorders. In addition, increased ambient temperature may increase workers’ exposure to hazardous chemicals and the adverse effects of chemicals on their health. Global warming will influence the distribution of weeds, insect pests, and pathogens, and will introduce new pests, all of which could change the types and amounts of pesticides used, thereby affecting the health of agricultural workers and others. Increased ambient temperatures may contribute to chronic kidney disease of unknown etiology among workers. Global warming is increasing ground-level ozone concentrations with adverse effects on outdoor workers and others. Extreme weather events related to climate change pose injury risks to rescue and recovery workers. Reducing the risks of work-related illnesses and injuries from climate change requires a three-pronged approach: (1) mitigating the production of greenhouse gases, the primary cause of climate change; (2) implementing adaptation measures to address the overall consequences of climate change; and (3) implementing improved measures for occupational health and safety.

Article

Street science is the processes used by community residents to understand, document, and take action to address the environmental health issues they are experiencing. Street science is an increasingly essential process in global urban health, as more and more people live in complex environments where physical and social inequalities create cumulative disease burdens. Street science builds on a long tradition of critical public health that values local knowledge, participatory action research, and community-driven science, sometimes referred to as “citizen science.” Street scientists often partner with professional scientists, but science from the street does not necessarily fit into professional models, variables or other standards of positivist data. Street science is not one method, but rather an approach where residents are equally expert as professional scientists, and together they co-produce evidence for action. In this way, street science challenges conventional notions in global health and urban planning, which tend to divorce technical issues from their social setting and discourage a plurality of participants from engaging in everything from problem setting to decision-making. Street science does not romanticize local or community knowledge as always more accurate or superior to other ways of knowing and doing, but it also recognizes that local knowledge acts as an oppositional discourse that gives voice to the often silent suffering of disadvantaged people. At its best, street science can offer a framework for a new urban health science that incorporates community knowledge and expertise to ensure our cities and communities promote what is already working, confront the inequities experienced by the poor and vulnerable, and use this evidence to transform the physical and social conditions where people live, learn, work, and play.