The World Health Organisation’s (WHO’s) Commission on the Social Determinants of Health points out that a girl born in South Africa can expect to live a life that is two decades shorter than one born in Japan.

A baby boy born in Gauteng or the Western Cape is likely to live a decade longer than another born in the Free State. In Sweden the risk of a woman dying during pregnancy is 1 in 17,400; in Afghanistan the odds are 1 in 8.

Human biology does not explain these large differences; nor are they a matter of chance. These differences are political; they are predominantly the result of differences in the social conditions, housing and quality of the environments in which people are born, live, grow, learn, work and age.

In 2014 and 2018 respectively, Michael Komape and Lumka Mkhethwa drowned in their schools’ pit toilets. Justifiably, their deaths were followed by widespread public outrage, and calls for preventive action, with the President himself playing a key role in the response. We should be equally outraged at the thought that thousands of children are needlessly dying each year before they have celebrated their fifth birthdays, or experienced even one day at school. They die prematurely because they live in housing that is hazardous to their health, and each time they get sick, we treat them and send them back to the very conditions that caused their ill health in the first place.

Housing is a particularly powerful determinant of the health and safety of young children. Among the reasons for the unique vulnerability of children to their living environments are that they have higher rates of respiration and ingestion than adults (and therefore take in more pollutants than adults), and their organ systems are incompletely developed, with a lower capacity to detoxify pollutants. Young children are also curious by nature and cannot always differentiate between food and non-food items, so may be seen to eat soil, sticks, stones, paint and other potentially unsafe or contaminated items.

Between the time of their birth, and going to school, children spend the major portion of their days in the home environment. Paradoxically, it is in their homes, where it might be expected that children would be safest, that they face the biggest threats to their health and safety.

In 2007 more than 61,000 South African children died before they had reached their fifth birthday. Nearly 40% of those deaths were from just two conditions that are strongly rooted in housing conditions: diarrhoea and pneumonia. Diarrhoea and pneumonia are also among the main reasons for the use of South African public healthcare services.

In poor settings, about one in five children with diarrhoea will return to hospital time and again for treatment of that disease. Recurrent bouts of diarrhoea may lead to malnutrition and lowered resistance to a range of other diseases, such as measles or pneumonia. The cost to families of repeated hospital admission of their children (or themselves) is significant, and includes transport outlays and loss of income from having to take time from work to seek treatment, and to care, for sick children.

Many other child deaths, such as from poisoning, drowning, burns and falls, are also often attributable to conditions in or around their houses; with proper action, the majority of these child deaths are avoidable.

Location, location, location

The estate agents’ economic adage of “location, location, location” rings very true also for public and environmental health. One of the simplest and most powerful ways of safeguarding the health of communities is to ensure that human settlements are developed on land that is as safe and clean as possible. This common wisdom was repeatedly flouted during the apartheid era, and our current democratically-elected government is also not blameless. To build settlements on the doorstep of mine tailings dumps, is to earmark those communities for chronic exposure to dust, toxic metals and radioactive substances that have been associated with respiratory problems, reductions in IQ scores, aggressive and violent behaviour, injuries and cancer, among other illnesses.

In the township of Riverlea (Johannesburg) for example, which is around 300 metres from the edges of a cluster of large gold mine dumps, and in which direction the predominant winds blow, more than half of the gardens have soil arsenic concentrations that exceed international guidelines. Children playing in those gardens are at risk of irritation of the stomach and intestines, blood vessel damage, skin changes, and reduced nerve function. There is also some evidence suggesting that long-term exposure to arsenic in children may result in lower IQ scores.

People living in houses built in the pollution path from coal-fired powered stations (or other relevant industrial sites), will predictably have elevated exposure to pollutants such as sulphur dioxide and particulate matter, leading to a higher risk of respiratory diseases. Planning practices that negligently place communities in polluted spaces may be seen as acts of environment and health injustice, usually against the most vulnerable in the country.

Currently there are only informal guidelines for exclusion zones between mining operations and housing settlements in South Africa. For example, one of these stipulates 500 metres as a “worst case scenario” and 1000 metres as a “best case scenario”. Even the 500 metre worst case exclusion limit has been flouted before and since 1994, with human settlements having been developed within such high risk zones.

Both the distances, and the informal, voluntary nature of the guidelines are problematic from a health point of view. To protect children and newborns from toxic exposures and health effects of mining and other industries, it is imperative that the government scale up their action to formalise mandatory health-based exclusion zones as a first step in protecting public health from the hazards of mining and industry-related pollution.

Interventions are also necessary to provide some degree of protection for the many unfortunate communities who have been living too close to mine dumps for decades, and on a daily basis, are exposed to the associated environment and health risks.

Housing is more than a roof over the heads of children

The quality of a family’s shelter is critical for the protection of their health and safety. Around 13% of dwellings in South Africa are described as informal. Included in this group are shacks made from flimsy materials such as metal sheeting, board and plastic, which will offer little protection against temperature extremes, strong winds and stormy weather, and may lead to serious injury or death. Leaky or uninsulated shelters allow high levels of dust to intrude into dwellings, increasing the likelihood of respiratory ill health effects. Cold homes increase the risk of high blood pressure and heart disease, while hot weather can lead to heat exhaustion and heat stroke, as well as higher levels of heart and kidney disease.

Because of changes in housing policy and terminology, it is challenging to accurately track progress on the delivery of healthy housing in South Africa. Undoubtedly, in the earlier years of democracy in the country, housing delivery programmes were significantly accelerated. For example, information from Statistics South Africa shows that between 1996 and 2016 the proportion of households living in informal dwellings decreased from 16% to 13%, despite an increase of 37% in the national population from 40.6 million to 55.7 million people over the same period.

What is clear however is that not all formal houses delivered have been of high quality. For example, about 20% of respondents in the 2016 Statistics South Africa Community Survey rated “RDP housing” as being of poor quality (as many as one third in the Eastern Cape). The majority of RDP housing was also developed well before the advent of climate change; poor quality RDP dwellings, as well as the 2 193 968 informal dwellings (Statistics South Africa; 2016 Community Survey) currently in existence in the country may be inadequate to withstand the stresses of extreme weather events and to protect the health of vulnerable households in years to come. A review of basic minimum housing standards relevant to the health stresses associated with climate change is required as a high priority in South Africa.

The Role of Water in Sanitation in the Burden of Diarrhoea

About 90% of diarrhoea is estimated to be caused by poor quality (or insufficient) water, inadequate sanitation and waste removal, and low levels of hygiene education. According to the 2016 South African Community Survey (Statistics South Africa), about 15% of households in South Africa do not have access to safe water. However, in reality, children in a much larger proportion of households may be using unsafe water on a daily basis. For example, just under one quarter of households in South Africa with a water supply report having had water supply interruptions in the previous three months.

Local South African Medical Research Council (SAMRC) studies indicate that in certain communities water supply interruptions occur much more frequently; on a weekly or more frequent basis. During such interruptions, many may use water from boreholes, streams, rivers, rainwater tanks and water tankers, where contamination is an important risk.

Also of health concern is the definition in South Africa of safe water as a piped source within 200 metres of the dwelling. Where water supply is frequently interrupted, or where water is supplied through a communal or yard standpipe (rather than inside the dwelling), households inevitably store water in miscellaneous containers for easy access.

Studies in villages around the town of Giyani in the Limpopo province showed that 97% of households stored water in containers, and that 18% of those containers were contaminated with Escherichia coli (micro-organisms that indicate faecal contamination). Direct observations often show insects and debris inside water containers, many of which are not routinely closed. Surprisingly, the study also showed contamination of water samples taken directly from the standpipe, which may be due to contamination of the tap, poor local water treatment practices or contamination from illegal water connections, amongst other factors.

The study team estimated that 1 in 4 households were at risk of drinking contaminated water, despite having a tap in their backyards. The 2016 Community Survey showed that issues related to basic environmental health services, such as water and electricity (including their cost) were cited as leading municipal challenges by 40% of participants interviewed.

Cooking with Wood, Coal and Paraffin, and what it means for Pneumonia

During the burning of wood, coal or paraffin for cooking and heating of dwellings, fine particles are released that may remain suspended in the indoor air for some time. These particles may be inhaled, and penetrate deeply into the lungs, where they may cause local inflammation, laying down the conditions for a higher likelihood of developing pneumonia and other respiratory diseases.

Children are often in the immediate vicinity of cooking fires in homes where fuels other than electricity are used; either playing or sleeping near their mothers, or being carried on their backs. Especially where old and poorly maintained stoves are being used, and where ventilation is poor, particles in indoor air my build up to high concentrations, which children may inhale. More than half of the global burden of pneumonia has been associated with exposure to indoor air pollution. Those using open fires or paraffin at home are also more likely to suffer burn injuries or unintentional paraffin poisoning.

Childhood Lead Poisoning

Thousands of studies around the world have left no doubt that lead is powerful brain toxin, and that exposure to lead in early childhood is associated with reductions in IQ scores, shortened concentration spans, learning difficulties, poor performance at school and aggressive/violent behaviour in early adulthood. In adults lead exposure is associated with kidney damage, high blood pressure and heart disease.

Health economists estimate that the loss of IQ points associated with lead exposure in children costs the South African economy around R262-billion in lost productivity each year. While the phase-out of leaded petrol and more recent controls on the use of lead in paint have been followed by laudable reductions in the blood lead levels of South African children, many children, especially the youngest and the poorest, continue to live in lead-exposed settings where little or no action has been taken.

These include children living in subsistence fishing communities (where lead is often melted to craft fishing sinkers, and where South African studies show that around three out of four first grade school children have lead poisoning) and close to certain mining operations, those living in houses painted with lead paint or from which lead-related cottage industries (spray painting, electrical repairs, motor vehicle repairs, jewellery manufacture etc) are operated, as well as those whose parents use firearms and ammunition.

A recently published SAMRC study shows that certain inner suburbs in Johannesburg may be hotspots for lead exposure. Around 65% of gardens had soil lead concentrations that were above international guideline levels. Children playing in those gardens, and who get soil onto their hands, may over time ingest considerable amounts of lead when placing their fingers in their mouths, chewing their nails or eating unwashed fruits and vegetables, for example.

Some children have a condition called pica (they eat non-food items such as soil or paint) and are at particularly high risk of lead exposure. Earlier studies showed that 70% of first grade school children in Bertrams had blood lead levels of 10 µg/dl or higher (reductions in IQ scores have been shown at blood lead levels as low as 3 µg/dl). The authors hypothesised that the very high levels of lead in Bertrams garden soil may be from a combination of factors, including the mixed residential and commercial land use in the area, old lead paint on local houses and the operation of cottage industries, for example.

Apart from the health effects, childhood exposure to lead early in life, has been associated with a reduced likelihood of achieving a tertiary education and lower earnings over their lifetimes relative to unexposed children.

Multiple housing-related threats to the health of poor children

The poor often bear multiple hazards to their health. For example, people living in an informal settlement that is also in close proximity to a mine tailings dump, may face health hazards from inadequate access to water, sanitation and waste removal services, as well as from the use of solid and liquid fuels for cooking and other household purposes, and tuberculosis in overcrowded conditions.

In addition, they may face health risks from exposure to mining-related dust, toxic metals and radio-active substances. If household members work within the mine, they may be at elevated risk of diseases such as silicosis, and may also bring some of the mine-related contaminants home on their hair, skin, shoes and clothing.

In addition, earning low wages may also mean that miners and their families are vulnerable to malnutrition. This combination of hazards to their health inevitably results in members of affected communities being unlikely to reach their full potential in life, or to contribute optimally to their families, communities and the national economy.

Healthy Children by Design

The place in which you are born and live as a young child, can determine the course of your life in multiple ways: physical and mental health status, educational achievement, lifetime earnings, exposure to violence and involvement in crime, social connections and the number of years of life you get to enjoy, to mention but a few.

In South Africa at the moment we have around 6-million children under the age of 5 years who find themselves living in houses that range from extremely opulent to highly degraded and unsafe. Most child diseases and deaths however, occur in those living in relative poverty and poor housing; it is their human and constitutional right to live in a safe and healthy environment that South African society may not currently be meeting. With the requisite political will, we could reduce the burden of disease and death in children by one quarter if we improved their housing conditions, especially those living in poverty.

It is possible to design housing that offers more than just a roof over the heads of its occupants. Housing that plays an instrumental role in reducing levels of pneumonia, diarrhoeal disease, lead poisoning, obesity, unintentional injuries, cardiac disease and cancer, amongst other diseases, and also promotes healthy lifestyles, is entirely feasible. Amongst the key ways to do this is to ensure that in South Africa we adopt the WHO Health in All Policies (HiAP) approach to development.

This would require that Health departments work closely with Treasury, Planners and Departments of Housing, Water, Sanitation, Industry, Energy and others to develop, alongside communities, to ensure that healthy communities are a common goal across all sectors and government departments.

There is also much to be learned from healthy housing success stories elsewhere in the world. We need to ensure that all housing is developed on land that is safe and health promoting, and that we adopt basic, minimum housing standards that are health-based and aligned with the definition of healthy housing as defined during the 1996 2^nd HABITAT Conference in Istanbul, as well as the forthcoming WHO Housing and Health guidelines that take account of the housing-related health implications of climate change.

The Johannesburg Declaration on Health and Sustainable Development that emanated from the World Summit on Sustainable Development held in South Africa in 2002, emphasised “healthy life remains a distant vision for many of the world’s people, particularly the poor, the marginalised, the displaced and refugees”; the thousands of South African children who die each year before they have reached their fifth birthday mostly count among this group.

The housing in which they live, as well as their poverty and inequality in South Africa, need to be addressed if we are to ensure that a girl or boy born in South Africa has the same health prospects as one born in Japan, and that a child in the Free State or Limpopo, has the chance to live the same length of life as another born in the Western Cape or Gauteng. Healthy environments and housing for South African children (and for all) are possible in a political environment in which we wage a serious and honest struggle to answer the question: why do we keep on treating children, only to send them back to the very conditions that caused their ill health in the first place? DM

Angela Mathee is the Director of the Environment and Health Research Unit at the South African Medical Research Council (SAMRC). Leonard Gentle is a consultant in Research Translation at the SAMRC. Glenda Gray is the President of the SAMRC