We all deserve to live in a clean environment: undernutrition and pollution in Ecuador

Introduction

Environmental pollution is related to around 24% of the global deaths, many of them consequences of non-communicable diseases (NCDs), such as ischemic heart disease, cancers, or obstructive pulmonary diseases. In addition, a large proportion of deaths result from communicable diseases, such as diarrheal diseases and respiratory infections (1). There are other serious health conditions such as chronic renal failure and undernutrition that are also directly or indirectly related with exposure to environmental determinants (2-4). It is not surprising to realize that the environmental burden of disease is 15 times higher in lower-middle income countries (LMICs) and low income countries (LICs) than in high income countries, due to differences in exposure to environmental risks and a lack of access to health care (5-7). Young children and elderly are more susceptible to the environmental impact on health: children under 5 years old are prone to develop infectious diseases such as parasitic diseases, lower respiratory infections, diarrheal diseases, malaria, neonatal and nutritional conditions; and adults from 50 to 75 years are predisposed to develop NCDs, such as cancers, unipolar depressive disorder, cardiovascular diseases, chronic obstructive pulmonary disease (COPD), asthma and musculo-skeletal diseases.

The main characteristic of the environmental risks is that they can be modifiable and thus preventable, a clean indoor and outdoor environment along with good water, sanitation, and hygiene (WASH) are the corner stone to ensure good health. Nevertheless, the coronavirus disease 2019 (COVID-19) pandemic has been a good example of how human health, animal health and environment are profoundly linked, pinpointing the concept of One Health (interactions between human, animal and environmental health) to properly address and prevent these public health issues (1,5,8).

Air quality

Indoor and outdoor air pollution has been associated with more than 7 million of premature deaths every year, around one tenth of those are children under 5 years old (1,9-11). Even though air pollution can affect high and upper-middle income countries due to industrial growth and global warming, the most affected populations live in LMICs and LICs, where adults and children are affected by common byproducts of industrial processes, traffic emissions, and by particulate matter (PM) derived from the combustion of biomass. These contaminants are significantly associated with cardiovascular and respiratory diseases (9,12-14), with low birth weight, preterm birth, infant mortality, anemia, and other health conditions such as congenital anomalies, and chronic undernutrition (3,15-19).

People spend most of their time indoors, especially in cold weather; therefore any contaminant in the air could affect their health in a highest proportion than outdoors pollution, due to prolonged exposure (20). More than three billion people still use biomass to cook and heat their homes, which predispose them to COPD specially in women, decreasing their life span and undermining their quality of life (21). Children are more prone to respiratory and gastrointestinal infections which leads to underweight, stunting, wasting, and anemia (17,22,23). Globally, in the poorest rural areas, babies and pregnant women are more vulnerable to pollutants, from the combustion of wood, charcoal, or dung as cooking fuel, because they spend more time indoors and directly exposed to the smoke (9,11,13,24). It is important to highlight that PM (<2.5 µm) are associated with those pathologies not just because of their physical properties, but for their chemical composition: persistent organic pollutants such as polycyclic aromatic hydrocarbons (8,11,25).

Soil contamination

The Andean Mountain Range crosses the Pacific coast of South America north to south, where heavy metals in low concentrations are natural components of its soil. Of note, anthropogenic activities such as mining and oil production, as well as the prolonged use of fertilizers and pesticides, increase the levels of contaminants such as As, Hg, Pb, Cu, Zn, Cd, Cr, and Ni (26-28), which can negatively affect the food chain, contributing to food insecurity, and resulting in a reduction of the availability of safe and nutritious food. This in turn rises the risk of human and animal diseases, impairing grow and development. The leaking of heavy metals, pesticides and fertilizers to superficial water bodies or even to deep water sources, worsens environmental complications, escalating public health concerns (29,30).

Water pollution

Unsafe drinking water and inadequate sanitation was responsible for 1.4 million premature deaths globally according to the 2019 Global Burden of Diseases, Injuries, and Risk Factors Study (31), most of the affected population are children and women from LICs and LMICs (1,5). Domestic sewage is associated with almost 80% of water pollution. Nevertheless, industries with poor practices discharge heavy metals, radioactive waste, plastic and polyethene products, or chemicals such as pesticides and fertilizers directly into water, affecting living organisms and human health (32,33). Another important source of human disease is contaminated food, perhaps due to cross contamination with water; in 2015 the World Health Organization (WHO) reported 31 selected hazards which resulted in around 420,000 deaths and 600 million illnesses worldwide, almost 40% of those affecting children under 5 years old, suffering from diarrheal diseases, which are responsible for millions of deaths, and also could be associated with chronic undernutrition (wasting and stunting) (34).

Undernutrition in Ecuador

Chronic childhood undernutrition has been defined as the proportion of children under 5 years old who present restricted physical development according with the WHO parameters (35). Currently in Ecuador, stunting affects 20.1% of children under 2 years old, 33.4% of whom are indigenous from the rural highlands of the country. Quito, its capital, has a prevalence of 23.3% of children suffering from undernutrition. It is of note that in the whole country, the highest prevalence of undernutrition is found in the population of the first and fourth income quintiles, 23.7% and 20.6% respectively; which, at least in this particular case, goes against the traditional way of thinking where undernutrition goes hand in hand with poverty.

Anemia is a condition that frequently goes along with undernutrition; globally, around 25.4% of children above 5 years old are anemic (36). In Ecuador, it is a common health issue throughout the whole country. Around 50% of children among 6 to 59 months old suffer from this condition, most of them living in the northern and southern provinces (37). Coincidentally these areas have many illegal mining operations.

It is important to highlight that 29.9% of the total Ecuadorian population still do not have access to clean water, and that 50% of what has been considered as “clean water” in rural areas of the country is contaminated with fecal coliforms. Moreover, eight of every 10 indigenous children lack access to clean water and sanitation (37). Water may not only be polluted with bacteria or heavy metals, it may also be contaminated with chemicals such as pesticides and fertilizers. Chancay et al. (38) reported the presence of pollution in fresh water of the Ecuadorian coast rivers produced by organophosphate pesticides (OPPs), such as Malation and Parathion, exceeding by several folds the maximum threshold determined in the US regulation; regulation; taking into consideration that Parathion has been banned in the country since 2009.

Discussion

Ecuador with its unique geographic and socio-economic context depicts the broader issues discussed in the precedent paragraphs; the interplay of lack of WASH, poor quality agricultural practices, and industrial activities without regulations oversight results in environmental pollution, which as it has been supported, is associated with infectious diseases as well as NCDs, and other health conditions such as undernutrition and anemia affecting mostly vulnerable population, not just physically but also their mental development (36). The question is: are Ecuadorian decision makers considering environmental pollution factors as determinants of health? And therefore, are they developing policies and designing interventions in order to control these health conditions considering the deleterious effect of environment contaminants?

Chronic childhood undernutrition could be one clear example that the approach of One Health has not being considered in the design and implementation of public health programs. The traditional approach to prevent undernutrition encompasses adequate maternal nutrition; breastfeeding; healthy diets, diverse and safe food; access to a healthy environment with safe WASH services, and practicing safe physical activity (7). These factors have been considered in around 12 programs implemented in Ecuador between 1993 and 2021, steered to improve health and nutrition (39); but despite all the repetitive efforts, the prevalence of chronic undernutrition remains one of the highest in the region (37). Undernutrition and anemia are multifactorial health conditions that must be addressed in a multidisciplinary and intersectoral manner, not just under the scope of the health sector (7,40). An unpublished work conducted by Universidad San Francisco de Quito at Simiatug, a community located in the bleak upland of the Bolívar province in Ecuador, reveals a prevalence of undernutrition as over 50% in children under 2 years old, most of them boys living in extreme poverty conditions, dwellers of houses provided with clean water but without any sanitation system available, where biomass fuel is still used in open fire for cooking. Some indoor air quality samples show concentrations of PM_2.5 Air Quality Guidelines (AQG) ranging from 50 to 100 µg/m³, well above the recommendation limit of an annual PM_2.5 AQG level of 5 µg/m³ (41). This demonstrates once again that environmental conditions are tightly related with public health problems.

Conclusions

It is irrefutable that environmental pollution directly and indirectly affects human, animal, and environmental health. These determinants interact with other social and economic factors such as poverty, lack of good WASH, poor education, and weak health systems, severely impacting vulnerable populations living in LICs and LMICs. Even though climate change affects the whole world, emerging and reemerging infectious diseases become a huge burden to the world’s poorest populations, due to their limited resources and lack of response capacities. The support of international organizations and stronger economies is essential to prevent the huge social and economic burden and consequences of high rates of morbidity, mortality, and disabilities in fragile communities. These are not the responsibility of a sole sector. Joint interdisciplinary and multisectoral efforts of academia, civil society, vulnerable groups, the private sector, as well as stablishing regional collaboration are indispensable to produce a positive impact on public health and change the future of LMICs and LICs populations that otherwise will continue to suffer from these dire consequences from environmental contamination on health outcomes.

Acknowledgments

Funding: None.

Footnote

Provenance and Peer Review: This article was commissioned by the Guest Editor (Mellissa Withers) for the series “Equity in Health: Findings from the APRU Global Health Conference 2023” published in Journal of Public Health and Emergency. The article has undergone external peer review.

Peer Review File: Available at https://jphe.amegroups.com/article/view/10.21037/jphe-24-46/prf

Conflicts of Interest: The author has completed the ICMJE uniform disclosure form (available at https://jphe.amegroups.com/article/view/10.21037/jphe-24-46/coif). The series “Equity in Health: Findings from the APRU Global Health Conference 2023” was commissioned by the editorial office without any funding or sponsorship. X.G.V. received study materials from the Universidad San Francisco de Quito and is part of the Board of the Institutional Review Board (IRB) of Universidad San Francisco de Quito. The author has no other conflicts of interest to declare.

Ethical Statement: The author is accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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