Environment & Health Research Unit

Executive summary Household Environment and Health in Port Elizabeth, South Africa

E. P. Thomas, J. R. Seager, E. Viljoen, F. Potgieter, A. Rossouw, B.Tokota, G. McGranahan, M. Kjellén.
Medical Research Council, South Africa; University of Port Elizabeth, South Africa;
Stockholm Environment Institute, Sweden

The Port Elizabeth Household Environment and Health study was undertaken in Port Elizabeth (PE) as there was an opportunity to link up with the Swedish funded development initiatives which had already been launched in the city. It is part of a four city comparative household environment and health series involving Jakarta, São Paulo and Accra.

Focusing on the environment and health problems at a household level, the study was structured to allow comparisons with the other three cities. As a result, the instruments used are similar to those used in the other city studies. They have, however, been adapted and are set up to highlight the disparities between wealth and health across the city. The study used a random sample of the whole population of the city and is thus able to examine city-wide disparities. In addition to the inter-city comparisons, each study focuses on the specific environment and health issues in a particular city, in this case PE.

The Port Elizabeth Council has been proactive in addressing the range of problems facing it. For example, innovative approaches have been adopted to address low income housing finance shortfalls, overall planning in the area and in setting up a local area budgeting system. A number of these initiatives have financial support from Sida. The Household Environment and Health study forms part of the Sida initiative to help to address the inequalities of the past in South Africa.

The aim of the study was to
Promote the well-being of communities in PE through research into health, housing and environmental issues, and in so doing to contribute to the understanding of the linkages between health, wealth and environmental conditions.

The objectives of the study were to

1. Describe a range of interconnected household environmental problems in Port Elizabeth
2. Compare the severity of these problems in different socio economic groups
3. Evaluate their health impacts
4. Assess people™s (and especially women™s ) priorities regarding improvements
5. Examine the financial, technological educational and institutional obstacles to improvement
6. Draw out some policy implications

Methods
The National Urbanisation and Health Research Programme of the South African Medical Research Council co-ordinated the study under the auspices of the Stockholm Environment Institute (SEI). A consultative process was followed whereby a local Steering Committee was elected by a community forum to oversee the project. The Institute for Development Planning and Research (lDPR) of the University of Port Elizabeth (UPE) and the PE Municipality played an active role in the fieldwork.

A number of complementary data collection methods was used to establish the environment and health conditions of households across the wealth spectrum. A survey of environment and health conditions was undertaken using a random sample of 1000 households representing the wealth spectrum of the city. A wealth index was used to classify the population into five groups of roughly equal size based on a proxy for wealth determined by ownership of consumer durables. A more detailed survey of a sub sample of 200 households was used to obtain further information on water and fuel use. The initial results of the 1000 household study were presented to the Steering Committee who helped to identify issues for discussion in focus groups. A total of nine focus groups on a range of topics was used to further explore the concerns of those living in lower income groups. Background reports into local government, environmental services, housing and NGOs were commissioned. This report synthesises the findings of the various components of the study.

In addition to this report, the preliminary findings have been presented to a number of fora including the Community Services Committee of the local Council, politicians, civil society leadership, non governmental organisations, local, national and international workshops and conferences.

Results
The results show wide disparities in access to services across the wealth spectrum. While this is typical of cities in developing countries, the data also highlight the relatively poor access to basic services by groups disadvantaged by past government policies. In addition, unequal access to education and therefore opportunities for income generation, in the past, is evident in a high rate of functional illiteracy in the lower wealth groups.

Taking a range of indicators into account, PE is clearly an urban area which is lagging behind the national urban average for access to basic services provided to its residents.

Housing and health
People in the lower wealth quintiles are exposed to risks in their homes related to the building methods and materials. The majority of homes in PE is constructed of brick but more than half of the people in the lower two wealth quintiles live in informal housing. Wood and corrugated iron sheeting are the main building materials for homes in the lowest wealth quintile (76%) and the lower-middle wealth quintile (54%). Problems experienced in the household environment by residents in the lower two wealth quintiles, include damp, thermal inefficiency, overcrowding and the siting of informal housing in poor locations. Other problems are related to poor ventilation rates in informal houses and the risks associated with paraffin (kerosene), the main cooking fuel used by those in the lower two quintiles. While the study showed that 80% of households using paraffin had soot on the walls and ceilings, and the focus groups reported negative health impacts of using paraffin, the adverse health effects of paraffin combustion products require further investigation.

Domestic water
All households have access to municipal supplies of purified water. While most households have access to water in their home or in the yard, 20% of the PE population relies on access to a communal water source. There are gender inequities in the responsibilities for the collection of water in that 80% of the water from communal sources is collected by women. Problems associated with the communal supplies include a lack of access to standpipes, long waiting times and large distances between homes and the standpipes. There was also evidence of deterioration of the water quality between collection point and consumption, highlighting the need for further monitoring and education. The low quantities of water consumed per person per day by users of communal sources are a cause for concern due to the likely adverse health implications (primarily skin and eye problems) associated with low volume water consumption. In addition, 14% of all households were dissatisfied with the taste and hardness of the water

Domestic sanitation
Those who experience sanitation problems are limited to the lower two wealth quintiles.  Those who have access to a sewered (flush) system did not identify any sanitation problems. 15% of the population of PE, which amounts to 24 000 households, are using bucket toilets. These people are predominantly in the lower wealth quintiles. Those who are concerned about their poor access to sanitation services believe that the PE local council is responsible for addressing this problem and people are aspiring to water borne sanitation as the solution. The high overcrowding rates in the middle wealth quintile is reflected in the fact that 20% of Coloured people share a toilet with more than 11 people. Puddles, flies and cockroaches at the toilet were associated with diarrhoea. The bucket system is the subject of much dissatisfaction by its users and water borne sewerage is seen as a priority. The main problems related to the bucket system seemed to be the inadequate emptying service provided by the Port Elizabeth Municipality (PEM). The impressions are that the PEM staff do not care, spill the contents and provide a service which is not regular enough.

Domestic waste removal
Littering is a concern of all the people in PE, especially the wealthier groups. Those experiencing and concerned about dumping and burning in their neighbourhoods are largely in the lower wealth quintiles. Burning and dumping problems seem to be related to the lack of waste removal services provided to the lower wealth areas. Backyard shacks and informal inillegallo settlements need to be provided with adequate refuse removal services. The provision of extra refuse bags may be part of the solution. It would appear that the improvement in refuse collection services and the state of general cleanliness in the lower income areas could go a long way to address the dumping and burning problems.  The cost effectiveness of providing containers rather than municipal refuse bags should be explored. There is a recognition that collaborative efforts are needed. Agencies which can play a role include the CBOs, neighbourhood groups and the municipality. The current pilot projects, may, if increased in scale be able to help to address the problems identified.

Urban pests
The presence of flies, cockroaches, rats etc., is a recognised problem in urban areas as they are carriers of disease. Not surprisingly, the pests are found far more frequently in the lower income areas where there are bucket toilets, refuse accumulates and animals are kept. Flies, mosquitoes, cockroaches fleas and ants were found in a quarter or more of all homes in PE. (Port Elizabeth is not in a malaria or dengue area so mosquitoes are more nuisance than health hazard). The lower-middle and middle wealth quintiles reported a slightly higher frequency of cockroaches than the other groups. Higher levels of diarrhoea were associated with having seen a cockroach in the last 24hrs. In low wealth households, flies were found much more often than in general in PE homes. A quarter (26,7%) of all low wealth households reported iealwaysls having flies around when preparing food and nearly half of all low wealth households (42,2%) reported flies ilalwaysls being in the toilet. In the case of flies in the cooking area and in the toilet, the problems experienced by the poor are nearly 3 times that of an average PE household. The most common measures used to address the problems of insects were aerosol insecticides, used in 20% of households on a regular basis. An average of R 12.83 per household is spent monthly in PE on pest control measures The total amount spent in Port Elizabeth privately per month on insecticides is equivalent to the City health budget for a month. In proportion to their income, lower wealth households tend to spend more on insect control measures than the wealthier households.

This is a further indication of the added burden faced by poor people living in areas with environmental hazards. 

Rats are often seen in the lower income areas. 60% of the lower two wealth quintile households reported having seen a rat in the previous week with half having seen one in the past 24 hours. In contrast, 70% of those in the highest wealth quintile had never seen a rat. Traps are used by approximately 60% of households but rats are seen to be such a prevalent problem that in half of the low income households no action is taken. Households who reported that dumping of solid waste occurs in their neighbourhoods, experienced a significantly higher number of pests in their neighbourhood.

Ambient air pollution
Pollution, burning of waste and other outdoor air problems were a problem across the wealth spectrum but focused in the lower wealth quintiles. Outdoor air pollution was noted as being a problem in over 50% of households. The low wealth quintile households were most concerned, with 85% identifying it as a priority issue to be addressed. In contrast, only 20% of high wealth quintile households experienced a problem with outdoor air quality. The main concerns were dust in the air, the burning of refuse and to a lesser extent, emissions from industrial activities. In nearly 50 % of households, the main problem was associated with dust (across the wealth spectrum) while the burning of refuse was the second most important source identified. 37% in the lowest wealth quintile complained about the burning of waste while in the upper wealth quintile, 22% identified this problem.  Emissions from industrial activities were of concern to over 10% of the households. Dust was raised as a particular problem by the focus groups.

Animals in urban areas
The desire to keep animals in the urban areas was identified as an issue by the Steering Committee. Many of those in the low wealth group said that they would like to have animals in urban areas, whereas only a few were found to actually keep animals. There is a tension between the desire to keep animals and the negative impact they have in urban areas, if uncontrolled. Those who have animals are seen not to control them and the animals cause a nuisance by scavenging, eating plants and defecating in the public areas. There is also a problem in the disposal of dead animals. Suggestions made by the focus group include the establishment of a controlling board to allocate land for this use and to set up and implement other control mechanisms. A clear stand by Council through a negotiated process will be needed to clarify how animals are to be controlled in urban areas, if allowed at all.

Conclusions
On reflection, it would appear that not only is PE a key urban area in an economically depressed province but that from a household health point of view, the residents of PE are further deprived in contrast to other urban areas in SA in their access to basic services.

The poor level of services to the area could be seen as an opportunity for further focused investment which will be able to address some of the backlogs in an innovative way.

Key aspects which emerge from the data comparing the full range of wealth groups is that the environment and health problems are focused in the lower wealth groups, in particular, the poorest 40% of the households.

These problems relate to

• access to potable water supplies which are convenient;
• a poorly managed and unhealthy bucket system of sanitation ;
• inadequate refuse collection services which results in littering, dumping, and burning;
• overcrowded housing which tends to be damp, have poor ventilation and temperature control and
• unemployment.

Each of the above problems have health concerns associated with it. Examples include

• those using public standpipes are more likely to use less water per person on a daily basis than recommended for good health;
• bucket toilets, refuse, dumping and burning were associated with the presence of rodents, vermin, flies and cockroaches and
• Children™s health is also compromised by living in poor environments with higher levels of ARI and diarrhoea.

Many of these problems will be addressed in time with the housing drive of the PEM. There is however, a need for urgent short term action. In addition, some policy initiatives are suggested.

Short Term Action
The study has shown that there is a need for improvement in the delivery of services by the PEM to ensure that the basic health and environmental safety needs of the poor are met.

These involve

• Rapid release of land with rudimentary services to address the overcrowding problem;
• Improved refuse removal system especially to those in the informally settled areas;
• Street cleaning;
• Improved bucket toilet removal services;
• Short term improved access to water by those reliant on communal water supplies;
• Health education drives to minimise the health problems which occur when basic services are inadequate;
• Involvement of community groups with Environmental Health Officers (EHO) to monitor the extent to which Council is providing an improved level of service to the community and to be able to provide feedback to the council service departments so as to help them to improve their service and
• Target the needs of vulnerable groups especially women and children in low income households.

Within the financial and other constraints facing the PEM and other local government structures in South Africa, there would seem to be opportunities to address the challenges.

It is suggested that efforts need to be made to

• Consider how the delivery of services can be fast tracked in such a way as to maximise the limited financial resources available to the PEM.
• Innovative approaches to helping the poorest of the poor to be accommodated in less overcrowded housing with improved levels of services need to be encouraged and explored.
• Deepen the culture of service in the PEM staff so that the services provided are undertaken in such a way as to respect the dignity of the residents in the area.
• Economic activity will be the only impetus to help the Council to address the problems in a sustainable manner. All avenues should be explored to encourage the generation of employment and economic activity.
• Encourage the role of EHOs as front-line PEM staff to help the Council to provide effective and efficient services to meet the needs of its community, and to
• Explore mechanisms to adopt an inter-sectoral approach to service delivery.

The report concludes with comments regarding more generic issues. These include a number of insights from the data regarding the exposure of certain groups to risks, the linkages of the issues at a household level and the need for appropriate responses. The section also highlights the inter-connectedness of the risks and suggests that there is a need for health and built-environment professionals to have a broader perspective of the linkages between health and environment issues in policy, management and implementation.

It is hoped that the initiative will inform policy and practice as well as lead to ongoing research to aid in the process of improving the health and environment of all residents in PE with a focus on the poor.