ENVIRONMENT AND HEALTH

Transcription

1 CHAPTER - 14 ENVIRONMENT AND HEALTH Cleanliness is next to godliness Mahatma Gandhi

2 This chapter attempts on Driving force, Pressure and State related to Environment and Health. It focuses on Urbanisation and their Impact. This chapter stress on Non-communicable disease (NCD) likes Anaemia and Communicable diseases like Tuberculosis, Rabies, Acute diarrhoeal diseases. Talks about Air and noise pollution, road traffic injury and also on socioeconomic determinants of health, stress on Nutritional status of children below 5 years of age and the diseases caused due to polluted water. It also focuses on continues experience, both acute and chronic adverse weather manifestations of climate change, and the consequent disruptions in physical, social, and economic conditions in the state leading to short- and long-term morbidity, heat-related illnesses, as well as catastrophic impoverishment, leading to suicides.

3 CHAPTER 14 ENVIRONMENT AND HEALTH 14.0 Driving Force Our environment impacts our health. We are constantly exposed to risk factors at home, work places and our commute to work or social interactions. The risk factors manifest in various forms, e.g., unsafe water and inadequate sanitation, air pollution, exposure to chemical, physical and biological agents, radiation, noise, adverse features of the built environment, including roads and housing, agricultural practices, and occupational health hazards. The World Health Organization (WHO) states that environmental impacts on health are uneven across the age spectrum, and mostly affect the poor. Children under five years of age, and adults between 50 and 75 years of age are vulnerable, and most affected by the environment. Likewise, low- and middle-income countries bear the greatest share of environment related diseases. An estimated 12.6 million deaths each year are attributable to unhealthy environments, which translates to approximately 23percent of global deaths. A recent WHO report systematically analyses and quantifies how different diseases are impacted by exposure to environmental risks. The comprehensive global assessment 1 concludes that premature death and disease can be prevented through healthier environments. Fortunately, now there is a greater awareness of, and demand by civil society, for safe-guarding our natural resources. Yet, there is plenty more to be done to protect the environment. This chapter outlines the pressures generated by the rapid growth in population, urbanisation and motorisation, etc., leading to the existing state of our communities, and the impact that the environment has had on us. The chapter summarizes the responses put forth in Telangana to combat some of the impacts, and discusses the gaps, where further research is needed to quantify the impacts of the environment on health in Telangana Pressure The state of Telangana is growing rapidly, as shown in the Table 14.1 there is access to government health facilities. Percentage of villages with Sub-Health Centre within 3km is 86%. Almost all Sub-Health Centres have Auxiliary Nurse Midwife (ANM). Although only half the PHCs are functioning on 24X7 hours basis, about 90% of them are PHCs having new born care services on 24X7 hour basis. At the community Health Centre level, almost all CHCs have 24X7 hours normal delivery services. At the District Hospital (DH) level, all DHs have ultrasound facility, and almost all DHs have critical care areas State Telangana state has a robust system of healthcare facilities, for the implementation of various national and state health programs. The state also has several urban Primary Health Centres in all districts, including 114 in the GHMC area. The Commissionerate of Health & Family Welfare, implements Maternal and Child Health Care and Family Welfare services, Family Planning, Antenatal Care, and Postnatal Care, including Immunization services in the State. The focus is mainly on primitive and preventive care. Table 14.2 shows the health facilities and infrastructure in the State. 398

4 Table 14.1 Access to Government Health Care Facility in Telangana Accessibility of health facility (%) Percent Villages with Sub-Health Centrewithin3km 86.3 Villages with PHC within10km 64.6 Availability of Health, Infrastructure, Staff and Services (%) Sub-Health Centre Sub-Health Centre located in government building 32.4 Sub-Health Centre with ANM 97.3 Sub-Health Centre with male health worker 25.4 Sub-Health Centre with ANM residing Sub-Health Centre quarter Where facility is available 46.2 Sub-Health Centre with additional ANM 73.8 Primary Health Centre (PHC) PHCs functioning on 24X7 hours basis 55.8 PHCs having Lady Medical Officer* 43.2 PHCs with atleast 4 beds 94.2 PHCs with AYUSH doctor* 40.5 PHCs having residential quarters for Medical Officer 21.8 PHCs having new born care service son 24X7 hours basis 90.2 PHCs having referral services for pregnancies/deliveryon24x7 hoursbasis 72.6 PHCs which conducted atleast 10 deliveries during the last one month On 24X7 hours basis 39.3 Community Health Centre (CHC) CHCs having 24X7 hours normal delivery services 97.6 CHCs having Obstetrician/Gynecologist 27.3 CHCs having Anesthetist 39.7 CHCs having a functional Operation Theatre 65.9 CHCs designated as FRUs 92.1 CHCs designated as FRUs offering caesarean section 29.6 CHCs having newborn care services on 24X7 hours basis 76.1 Sub Divisional Hospital(SDH) SDHs having Pediatrician 72.7 SDHs having regular radiographer 9.1 SDHs having 2DEcho facility 0.0 SDHs having Ultrasound facility 72.7 SDHs having three phase connection SDHs having critical care area 75.7 SDHs having suggestion and complaint box 69.7 District Hospital (DH) DHs having Pediatricians 77.8 DHs having regular radiographer 55.5 DHs having 2D Echo facility 22.2 DHs having Ultrasound facility DHs having three phase connection DHs having critical care area 88.8 DHs having suggestion and complaint box 55.5 Source: DLHS 4: Telangana 399

5 Table 14.2 District wise Health Facilities in Telangana State District Sub Centres PHCs CHNCs CHCs PP Units UFWCs UHCs Area Source: Commissionerate of Health and Family Welfare, Government of Telangana Hospitals District Hospitals Mahabubnagar Ranga Reddy Hyderabad Medak Nizamabad Adilabad Karimnagar Warangal Khammam Nalgonda State Table 14.3 Shows the Health Indicators in Telangana State District Adilabad MMR IMR TFR CPR*** CBR ASR CR Full Immunization * 2013* 2013* 2013* 2011* 2011** , Nizamabad , Karimnagar , Medak Hyderabad Rangareddy Mahabubnagar Nalgonda Warangal Khammam , State Source:1.*-Commissionerate of Health and Family welfare, Hyd. 2.**-Census2011, 3.***-DLHFS IMR Infant Mortality Rate (per 1000 livebirths) MMR-Maternity Mortality Ratio (per 1 lakh live births) TFR Total Fertility Rate CSR-Child Sex Ratio (per 1000 males) CBR-Crude Birth Rate SR-Child Sex Ratio (per1000 males) CPR-Contraceptive Prevalence Rate ASR- Adult sex Ratio (per 1000 males) 400

6 Telangana has been home to traditional industries like heavy metal processing, and pesticide manufacturing, etc. For the past decade, Telangana State (mainly due to the city of Hyderabad) is emerging as a major hub for information technology, bio-tech and the pharmaceutical industry. The lack of physical barriers to its growth in all directions, and the investment-friendly policies of the government are aiding Hyderabad to be an attractive investment destination in India. However, these policies are not able to keep pace with the ever-increasing demand for affordable housing and transportation in the city. The rapid growth of the city, combined with rising income levels, and a weak public transport system is leading to a massive increase in the growth of personal vehicles. The result is recurrent traffic congestion, high levels of pollution, and an increased risk of road traffic injuries. There are several impacts of transport. While the positive impacts are better connectivity, and rapid transfer of goods and services, there are also negative impacts, e.g., road injuries, or respiratory conditions as a result of air pollution. Economic impacts could be at an individual level, e.g., catastrophic expenditure for healthcare because of disability due to road injuries, or at the population level, e.g., the cost of road building. Social impacts could be in the form of an aspiration for a more comfortable mode of travel, or the pressure to buy a motorised vehicle, or alienation from the rest of the community because a new highway cuts across a village. Environmental impacts could be through depletion of energy, especially fossil fuels, oil resources, or the loss of agricultural lands for road building. The economic costs of road networks is huge, even if only the direct costs of highway land capital expenses, road building and widening, maintenance, administration and policing are considered. Indirect costs include, but are not limited to, government subsidies for fuel, rehabilitation, and cost of pollution. Personal costs consist of vehicle purchase; maintenance; insurance; fuel, parking; and costs related to road congestion- vehicular wear and tear; missed opportunities; and wasted time and fuel. Healthcare demands arising from transport impacts, such as traffic injuries, disability, and chronic diseases are staggering. Families can be pushed into poverty, especially if these are out-of-pocket expenses. Road traffic injuries are discussed in more detail, in following sections. Similarly, social costs are enormous if we include the impacts of inequity, division, wages lost, and poor quality of life, of populations displaced for road construction. Social inequity and community severance is caused by major roads being built through a community, with a proportion of local residents being cut off not only from safe and easy access to shops, schools and other facilities, but also from their social network Motorisation India is motorising rapidly. Increasing household incomes, easy availability of loans for purchase of vehicles, and an aggressive automotive industry are leading to a substantial increase in motorised transportation. Passenger cars are growing at 12 percent annually, and 2-wheelers registered a growth of 2 14 percent in The high rate of motorisation is estimated to be associated with over 500,000 road 3 traffic injuries each year, according to official reports. Road injuries are projected to increase with 4 increasing motorisation and road deaths are predicted to increase two and a half times by 2020 The increased travel demand has resulted in rapid growth in the number of motor vehicles in the cities. This growth is largely driven by the growth in the number of 2-wheelers. It is especially high in cities without a mass transit system, such as Hyderabad. Also, as income levels go up, the transition is made from nonmotorised transport and public transport, to motorised 2-wheelers like scooters and motorcycles. India currently has about 15 million cars, which is equivalent to 13 cars per 1,000 population (157 cars per 5 1,000 population in Delhi, and 72 cars per 1,000 population in Hyderabad while this by itself is not high, compared to 450 cars per 1,000 persons in USA and Japan, it is likely to increase three fold by It is estimated that there will be about 35 cars per 1,000population on average, and in some cities, more than 300 cars per 1,000 population. This would amount to about million cars on Indian roads. This exponential growth in the number of cars will have serious implications for energy security; air pollution, 401

7 road safety; equitable allocation of road space; and will accentuate problems related to parking and congestion, which many Indian cities have already started witnessing. The transport sector in India is the largest consumer of petroleum products at 55percent and cars presently consume nearly 20 percent of 5 fuel Urbanization Urban India is witnessing phenomenal growth. According to the 2011 census, India has a population of 1,221 million with approximately 32percent (390 million) living in urban areas. The share of the urban 6 population is estimated to increase to between 40 and 75 percent of the total population by the year Many cities in India have experienced rapid growth in the past few years. This has opened up many opportunities, especially in terms of business and commerce. It has also lead to several challenges for the governance of these megacities, especially in the provision of safe and efficient transport connections. Transport demands in Indian cities are increasing rapidly due to urbanisation and an increase in population. The shift from non-motorised to motorised transport, especially 2-wheelers and cars in India, is partly due to unreliable public transport which is perceived as lacking flexibility and comfort. Details of Urbanization in each district of Telangana is discussed in Chapter - 12 on Urban Development Impact There are several impacts of the environment on health, some of which are the cause of non-communicable diseases; pollution; etc., and, some, communicable diseases like diarrhoea, vector-borne and other diseases. Adverse health conditions can result from built environment related impacts, e.g., physical inactivity leading to obesity; hazardous road conditions leading to traffic injuries; poor immediate environment and living conditions leading to increasing crime, and so forth Non-communicable disease (NCD) The burden of NCDs in Telangana is high. A recent multi-state research study on the regional variation in the prevalence of selected NCDs included some districts of Telangana. The study found a pooled prevalence of overweight/ obesity to be 40percent, that of hypertension to be 24 percent, and that of diabetes to be 12 7 percent. Most of these conditions are due to sedentary lifestyles, unhealthy food choices, and built environment related causes. Table 14.4 shows the blood sugar level and hypertension in Telangana. The prevalence of diabetes is shown to be around 10%, and the prevalence of hypertension is around 28%. Table 14.4 Blood sugar level and Hypertension in Telangana Blood Sugar Level ( age 18 years and above)(%) Total Rural Urban Blood Sugar Level>140mg/dl (high) Blood Sugar Level>160mg/dl (very high) Hypertension (age 18 years and above)(%) Above Normal Range(Systolic >140mm Hg & Diastolic >90mm Hg) Moderately High (Systolic >160mm Hg & Diastolic >100mm Hg) Very High (Systolic >180mm Hg & Diastolic >110mm Hg) Source: DLHS-4: Telangana The prevalence of chronic illness during the last one year in Telangana is reported to be around 16% (Table 14.5), with cardio vascular diseases accounting for the majority. 402

8 Anaemia Status by Haemoglobin Level (%) Total Rural Urban Ministry of Environment, Forest & Source: DLHS-4: Telangana 14.7 Anaemia Table 14.5 Prevalence of chronic illness during last one year in Telangana Reported Prevalence of Chronic Illness during last one year (%) The prevalence of anaemia in some districts of Telangana is high. A recent study from Karimnagar found the 8 prevalence of anaemia to range from 41 percent in males to 60percent in females. There are several variants of anaemia, and as reported by another study in Karimnagar, where children of age 2 months to 14 years admitted in tertiary care hospital were assessed. It was found that 58% of children were anaemic due to iron deficiency anaemia, 27 % were having sickle cell disorder, 9% were having thalassemia, 5 % had 9 megaloblastic anaemia and 2% had aplastic anaemia. The district level household and facility survey-4 for Telangana state reported that 51 percent of adolescents aged 15 to 19 years, had anaemia, and 62 percent 10 of adults, aged 15 to 49 years had anaemia. Table 14.6 shows a high prevalence (71%) of anaemia among children aged 6-59 months. The high prevalence continues among children aged 6-14 years, and years, and also among reproductive aged women of years. Overall, half the people aged 20 years and above are reported to have anaemia in Telangana. This is a disturbing trend and needs urgent attention. Table 14.6 Anaemia status in Telangana Total Rural Urban Disease of respiratory system Disease of cardiovascular system Persons suffering from tuberculosis Children(6-59months) having anaemia Children(6-59months) having severe anaemia Children(6-9Years) having anaemia -Male Children(6-9Years) having severe anaemia -Male Children(6-9Years) having anaemia -Female Children(6-9Years) having severe anaemia -Female Children(6-14years) having anaemia-male Children(6-14years) having severe anaemia-male Children(6-14years) having anaemia-female Children(6-14years) having severe anaemia-female Children(10-19Years) having anaemia-male Children(10-19Years) having severe anaemia-male Children(10-19Years) having anaemia-female Children(10-19Years) having severe anaemia-female Adolescents(15-19years) having anaemia Adolescents(15-19years) having severe anaemia Pregnant women(15-49aged)having anaemia Pregnant women(15-49aged)having severe anaemia Women(15-49aged)having anaemia Women(15-49aged)having severe anaemia Persons(20 years and above)having anaemia Persons(20 years and above)having severe anaemia Source: DLHS-4: Telangana 403

9 14.8 Air pollution Air pollution and the resultant impact in India could be broadly attributed to the emissions from vehicular, industrial, and domestic activities. 11 India is reported to harbour 13 out of the world's 20 most polluted cities. The air quality of Hyderabad is deteriorating with the transportation sector being the largest contributor (70 percent) of emissions in the city. Further, the annual particulate matter (PM 10) levels in the city are in the critical range of ìg 3 12 /m, so much so that 90 percent of residents identified congestion to be the main problem in Hyderabad. Another recent study confirmed that the air pollution in Hyderabad is on the rise. The ambient air quality levels particulate matter at most of the air quality monitoring stations of Hyderabad exceeded the 13 prescribed limits 14 Studies indicate that children living near roads with heavy traffic are at greater risk of respiratory disease. More than a third of the schoolchildren in four big cities of India suffer from reduced lung capacity, with 15 Delhi showing the worst results Noise Road traffic noise is shown to affect communication, school performance, cardiovascular health, sleep, and temper, and could lead to hearing impairment. Analysis of traffic in Hyderabad revealed that four out of six traffic intersections had exceeded tolerable limits of noise. Other NCDs due to, and common health effects of motorised transportation include respiratory conditions and allergies due to air pollution, low back pain due to time spent in vehicles, fatigue, stress, depression, obesity, and certain types of cancers, and non-communicable diseases like diabetes, cardiovascular diseases and osteoporosis. The wider physical environmental impacts of transport are through vehicular exhaust and greenhouse gases, leading to global warming and rise in temperatures Communicable diseases Despite the epidemiological transition, the burden due to communicable diseases continues to be high, as shown in the table 14.7 For instance, 9361 cases of Malaria were reported in Telangana in 2015, followed by 101 cases of Japanese Encephalitis (JE). Telangana also had 1831cases of Dengue and 2067 cases of Chikungunya in These vector borne diseases are of serious concern because of their seasonal nature and debilitating consequences, especially for people earning daily wages for their livelihood. Variables and cases Table 14.7 Vector Borne Diseases in Telangana Status in India vs Telangana Annual Blood Examination Rate(Malaria) per 100 population 2.20 Annual Parasite Incidence (API) for Malaria per 1000 population 0.02 Malaria Cases reported 2015 India Telangana9361 Suspected cases of JE 2015: India 8079 Telangana101 Suspected cases of Dengue 2015: India Telangana1831 Cases of Chikungunya 2015: India Source: National Vector Borne Disease Control Program of India Telangana

10 17 There is still a big burden of vector borne diseases like Dengue and Malaria. There were 595 infected 18 H1N1 (Swine Flu) cases in The year 2015 saw an unprecedented increase in the number of cases of H1N1 (Swine Flu). The rate of H1N1 infection in 2015 was an all time high affecting 2,956 persons out of 12,639 samples tested, of which 101 deaths occurred. Out of total tested 23.3% were positive and out of total positives 3.4% were deaths. District wise H1N1 (Swine Flu) cases during 2015 are shown in Table Table 14.8 H1N1 (Swine Flu) Cases in 2015 Source: Office of the Director of Public Health and Family Welfare, Govt. of Telangana In 2016 number of samples tested for H1N1 was 4422 and confirmed positive cases were 166, of which 12 deaths occurred. Out of total tested 3.7% were positive and out of total positives 7.2% were deaths. District wise H1N1 (Swin flu) cases during 2016 are shown in Table Table 14.9 H1N1 (Swine Flu) Cases in 2016 Source: Office of the Director of Public Health and Family Welfare, Govt. of Telangana 405

11 14.11 Tuberculosis One fourth of the annual global incident TB cases are from India(Figure 14.1).The WHO estimates (2015) that in India there are 2.2 million new cases (167/100,000) and the prevalence is 2.5 million 19 (195/100,000). Mortality from TB is 0.22 million (17/100,000) annually. 3% of new cases and 12-17% of re-treatment cases are multi-drug resistant (MDR) in India (resistance to both INH and Rifampicin) Million TB patients have MDR in India.91,32,306 suspects were screened for TB using sputum smears in 2015 and 14,23,181 cases registered for treatment in India.5% of incident TB patients in India are HIV positive. In Telangana, 206,549 suspected cases were examined in 2015 and 27,794 smear positive patients were detected. A total of 39,498 patients were registered for treatment in 2015 in Telangana. 17% of all TB cases notified in 2015 in Telangana were extra pulmonary TB. 7% of all registered TB cases in Telangana were HIV positive in 2015.Government TB and Chest Hospital is a tertiary care facility in Hyderabad and has 670 beds. This is the biggest TB hospital in the public sector in Hyderabad and handles a large proportion of TB case management in the State Rabies Figure 14.1 Tuberculosis cases 36% of the world's rabies deaths occur in India each year. This translates to more than 20,000 deaths every year. Most cases are reported from Maharashtra, Tamilnadu, Uttar Pradesh, West Bengal, Goa, Telangana and Andhra Pradesh. Rabies is a notifiable disease in India. The disease is caused by the Rhabdoviridae family which affects the nervous system of mammals. It is 100% fatal and there is no treatment once the disease develops. In India, dogs are responsible for 97% of human rabies. It is estimated that there are 25 million dogs in India, most of which are stray dogs. To reduce transmission of rabies, 70% of dogs should be effectively immunized. India produces 15 million doses of human rabies vaccine and half a million doses of equine rabies immunoglobulin annually. 406

12 Rabies spreads though close contact with infected saliva via licks, bites or scratches. Rabies is 4 times more common in males as compared to females. 50% of the cases are seen in the age group of 6-15 years.17 million dog bites are reported annually in India but only 3 million receive the anti-rabies vaccine. Timely and appropriate treatment can prevent the onset of rabies in virtually 100% of exposures. Equine or human derived rabies immuno-globulins (RIG) should be administered at multiple sites away from the vaccination site. Unfortunately the supply of RIG is irregular. The Institute of Preventive Medicine, Hyderabad reports 50,000 cases of animal bites annually. In 2014, the Infectious Diseases Hospital, Hyderabad, reported 23 deaths due to rabies Acute diarrhoeal diseases Acute diarrhoeal diseases are highly prevalent in India and affect all age groups. In 2015, integrated disease surveillance project (IDSP) in India reported 450 outbreaks of acute diarrhoeal diseases, 328 of food poisoning and 45 outbreaks of Cholera across the country. In 2014, 116,73,018 cases of acute diarrhoeal diseases were reported in India and 1323(0.01%) deaths reported. Acute Diarrhoeal Disease(ADD) cases in 2015 are shown in Table In Telangana state two Outbreaks of ADD were reported in 2016, one at Hyderabad and another in Adilabad. In Hyderabad 100 cases of ADD st reported in 1 week of July 2016 in Lallaguda, Secunderabad and in Adilabad 126 cases were reported in Boath in July Epidemiological investigation revealed that the Outbreaks were due to poor environmental sanitation and contamination. S.No Table Acute Diarrhoeal Disease(ADD) cases in 2015 Acute Diarrhoeal Disease (ADD) Name of the District Cases Deaths 1 Mahabubnagar Rangareddy Hyderabad Medak Nizamabad Adilabad Karimnagar Warangal Khammam Nalgonda TOTAL Source: Office of the Director of Public Health and Family Welfare, Govt. of Telangana Cholera is still prevalent and India is considered one of the endemic countries. WHO estimates that annually 670,000 people of all ages have diarrhoea due to cholera of which 20,256 die in India. Cholera outbreaks have recently been reported from South India which was earlier considered to be relatively less problematic. Cholera has been reported from few regions of Telangana State this year including Hyderabad in July National Family Health Survey (NFHS-4) results from Telangana report that 8.4% of children under 5 years of age had diarrhoea in the preceding two weeks. 407

13 There is a fairly high level of awareness among mothers in Telangana regarding diarrhoea and respiratory infections. The table below shows that about 73% of the women in Telangana know what to do when a child gets diarrhoea. Similarly, 64% of women are aware about the danger signs of acute respiratory infection (ARI). The table also shows that approximately 60% of the children with diarrhoea in the last 2 weeks had either received oral rehydration solution (ORS), or had sought advice/treatment for diarrhoea. Proportion of children with acute respiratory infection or fever in last 2 weeks and had sought advice/treatment was 82 %.( Table 14.11) Source: DLHS-4: Telangana Table14.11 Awareness about Childhood Diseases and Treatment in Telangana Awareness about Diarrhea (%) Total Rural Urban Women know about what to do when a child gets diarrhea Awareness about ARI (%) Women aware about danger signs of ARI Treatment of childhood diseases (based on last two surviving children born during the Reference period)(%) Prevalence of diarrhea in last 2 weeks for children under 5 years Children with diarrhea in the last 2 weeks and received ORS Children with diarrhea in the last 2 weeks given Zinc along with ORS Children with diarrhea in the last 2 weeks and sought advice/treatment Prevalence of ARI in last 2 weeks for children under 5 years Children with acute respiratory infection in last 2 weeks and sought advice/treatment Road traffic injury Globally, 1.2 million deaths and million injuries are caused each year as a result of road traffic 20 crashes. The worst affected are young adults aged 15 44, and vulnerable road users, like pedestrians, cyclists and motorcyclists. About 91percent of global road traffic deaths occur in low or middle-income countries, despite their having only half the world's vehicles. Worldwide, road traffic injury is the leading cause of death among young people aged 15 to 19 years, and is the second leading cause of death among those aged 5 to14 years. An estimated 180,000 children are killed annually, with 93percent of child road 21 deaths occurring in low or middle-income countries. Road injury is a growing public health problem in India, a middle-income country in the WHO's South East Asia region. An estimated 231,000 fatal road 22 injuries were recorded in India in 2010, accounting for about 70percent of all road traffic deaths in the region. According to official statistics in 2013, the rate of road traffic crashes, injuries and deaths per 100,000population in India was 38.9, 39.6 and 11.0 respectively. Approximately half of all deaths on India's roads are among vulnerable road users, i.e., motorcyclists, pedestrians and cyclists. Road injury is a mounting concern for the government, parents and schools, especially in urban India. Hyderabad is one of the fastest growing urban areas in India and is also motorising rapidly. Poor road safety is a cause for concern, as road injuries have been increasing. The number of road injuries was up from in 2013 to 2540 in 2014 in Hyderabad. In 2014, the number of road crashes and deaths in Hyderabad were 2585 and 358 respectively. Figure 14.2 shows that Hyderabad reported 97 road traffic injuries per 100,000population in 2013, with 24.5 deaths per 100,000 population. 408

14 RTCs per 100,000 population Fatal RTIs per 100,000 population RTIs per 100,000 population Source: Data from Hyderabad traffic police, compiled in the final report of the Bloomberg philanthropies' Global Road Safety Programme (unpublished report) Figure 14.2 Trend of road traffic crashes, injuries & deaths -Hyderabad ( ) The effect of road traffic injuries in India is important: they are a major cause of hospitalization, disabilities, and health related socioeconomic losses. This is because the economically productive age group is the most affected due to road traffic injuries. About 2.2 percent of the Indian population is estimated to have some form of disability. Injuries are estimated to be responsible for one-third of these 23 disabilities, with road injuries contributing to nearly half of the total injury disability. The high burden of road injuries has been documented to be associated with catastrophic out-of-pocket medical 24 expenditure Physical activity Physical activity is any form of muscular movement that expends energy and has numerous health benefits for children and youth. The dose-response relationship indicates that the more the physical activity, the greater the health benefit. Daily physical activity can be accrued through walking and cycling to work or school. Although active commuting alone may not be enough to fulfil the physical activity requirement, it can contribute to the daily overall amount of energy expenditure, and help prevent the development of chronic diseases. It is therefore important to encourage people to walk and cycle because it has been shown to have positive long-term health and societal benefits by promoting healthy behaviour from an early age. Previous studies have documented significant relationships between greater active commuting and positive health indicators, 25 including lower body mass index, healthier blood lipid profiles, and lower blood pressure. Lack of physical activity is now known to be a major risk factor for a range of non-communicable diseases, including heart disease, colon and breast cancers, diabetes, and depression. The World Health Organization estimates that as many as 3.2 million deaths each year are related to physical inactivity. The Global Burden of Disease study (2010) further confirmed that lifestyle-related illness is a growing problem in both high and middle-income countries. By 2030, it is estimated that Indians 26 will be 14 percent less physically active than they were in

15 The Global School Based Health Survey to assess health behaviours among 13 to 15 year old children in 34 low and middle-income countries including India showed that only 23 percent of boys and 15 percent of 27 girls met the physical activity recommendations. It is important to note two points about built environment here: (i) Studies have identified traffic as a major risk factor for the development of obesity in 28 children. This means that how we design our cities and communities directly affects our health. (ii) Physically active children are likely to continue to be physically active adults Socioeconomic determinants of health According to the DLHS-4, as presented in Table The majority of households in Telangana have electricity and safe drinking water. However, access to improved toilet facilities is low across the state, particularly in rural areas. Likewise, access to clean fuel for cooking is low across the state, especially in rural areas. These deficits have a strong influence on susceptibility to communicable and noncommunicable diseases, such as diarrhoeal diseases and chronic respiratory disorders. Further, the lack of access to such basic amenities for health and safety can have serious, long-term impact on opportunities for educational, employment, and recreational pursuits, and quality of life, particularly for vulnerable segments of the population, such as women and children. Table Households with access to basic household amenities Percentage of Households Total Rural Urban Having electricity Improved source of drinking water Having access to improved toilet facility Use clean fuel for cooking Source: DLHS-4: Telangana Nutritional status of children below 5 years of age As Table below reveals, approximately 13 to 30 percent of children under the age of 5 years in Telangana are malnourished, with the prevalence of wasting, stunting, and underweight marginally higher in rural areas than in urban areas. This raises a flag for the government and civil society organisations in the state to assess contributing factors and take steps to raise awareness of nutrition, and institute facilities to support improved nutrition for children, as well as other age groups. Table Nutritional status of children below 5 years in Telangana Nutritional Status Total Rural Urban Children below 5 years wasting (weight for height-below2sd) Children below 5 years wasting (weight for height-below3sd) Children below 5 years stunting (height for age-below2sd) Children below 5 years stunting (height for age-below3sd) Children below 5 years under weight (weight for age-below2sd) Children below 5 years under weight (weight for age-below3sd) Source: DLHS-4: Telangana Table below shows the prevalence of personal habits among people of Telangana. It shows that 21% of men in the rural areas and 12% in urban areas use smokeless tobacco. The prevalence of smoking is even higher among rural men (28% among rural and 22% among urban men). The prevalence of alcohol consumption is also high among rural men (38%) compared to urban men (34%). The prevalence of smoking and drinking among women is much lower. (Table 14.14) 410

16 Table Personal Habits (smoking and alcohol) in Telangana Personal Habits (age 15 years and above) (%) Total Rural Urban Men who use any kind of smokeless tobacco Women who use any kind of smokeless tobacco Men who smoke Women who smoke Men who consume alcohol Women who consume alcohol Source: DLHS-4: ( ) Quality of drinking water Contamination of drinking water, frequently with E. coli, has been reported. It is estimated that out of the 688 km of the Water Board pipelines in Hyderabad, 324 km is old. It is perhaps through these damaged 29 pipelines that water contaminated with bacteria enters the drinking water. A fluoride concentration of 1ppm (1mg/L) in potable water is essential for healthy teeth and bones. However, at higher concentrations (>1.5 ppm), it has adverse effects such as causing dental and skeletal fluorosis. Fluorosis is one of the major health risks faced by people in Telangana. Mahbubnagar, Nalgonda, 30 Karimnagar districts are some of the affected districts Crime Crime is affected by the immediate environment. Cases of crime against women rose by eight percent in 2015, compared to the previous year, under Hyderabad Police Commissionerate limits in Hyderabad. The total cases of crime against women were 2,518 this year as against 2,335 recorded in the previous year. Total accidents under Hyderabad limits increased by 18 per cent with 3,896 accidents reported during this year as against 3,293 last year resulting in death of 1,156 persons and injuries to 3,499 this year as against 31 1,033 and 3,329 last year respectively Climate change Climate change is a real and progressing threat to global health. The Telangana region has experienced, and continues to experience, both acute and chronic adverse weather manifestations of climate change, and the consequent disruptions in physical, social, and economic conditions in the state. Repeated droughts, heat waves, and cycles of failed as well as heavy unseasonal rains, particularly over the past decade, have resulted in short- and long-term morbidity, numerous lives lost directly to heat-related illnesses, as well as catastrophic impoverishment, leading to suicides. Heat-related mortality statistics vary among reporting entities: mass media reports set the toll at over 300 in the summer in 2016, whereas different government departments report other numbers. The discrepant reporting may be attributed to the criteria for declaring a death heat-related, as well as inaccurate reporting to take advantage of the compensation offered by the government to kin of heat-related casualties. Heat-related adversity is compounded by the intensifying scarcity of adequate, safe, and accessible water, through the plummeting ground water table, the progressive loss of surface waters, and the changing physical, chemical and biological composition of the available water. Water stress has affected the physical health as well as social and economic conditions of the population. Water scarcity is reported to have influenced personal hygiene practices, including reducing the frequency of washing, and the practice of treating water for safety before consumption, as well as compelling people to buy water for domestic use. Outbreaks of water-borne diseases related to particular sources of water are also reported, e.g., gastroenteritis in residents in a colony in Chilkalguda, Hyderabad, in July The depleting green cover in Telangana, which stands at approximately 24 percent at present, both contributes to, and suffers from, climate change in the state. Telangana ku Haritha Haram, a much publicized initiative of the state government, launched in 2016, aims to enhance the state's green cover to 33 percent, by intensive plantation in forest as well as non-forest areas. 411

17 14.21 Response The government's response has been through special programs, especially for the vulnerable population. It has initiated mostly vertical health programs to improve maternal and child health, adolescent and school health, as well as tribal health. But as the population continues to grow, along with inflation, the demand for affordable health care is ever-increasing. Besides government initiatives, civil society has taken strides in spreading awareness of climate change and environment degradation by human activities. Each year, citizen groups also educate the population on the advisability of environment-friendly cultural practices, and the ills of water-pollution, air-pollution, threats to biodiversity, and enhanced disease risk consequent on the use of materials such as disposable plastics and harmful chemicals, and unsafe disposal of domestic, industrial, agricultural and municipal waste in water bodies, as well as the burning of garbage. Through specialty markets on a small scale, and the promotion of organic agricultural practices, the population is gradually getting increased access to safer alternatives to materials and foods that are environmentfriendly and healthy. The Food Safety and Standards Authority of India has established regulatory structures for food safety at central and state levels, for the licensing, accreditation, and periodic inspection of food products, food production and sales outlets, and food handlers. The facilities and executives in Telangana, as of November 2014, are reported in the Table Contemporary lifestyles are associated with the generation of large quantities of waste, of different kinds: compostable, recyclable, inert, electronic, and hazardous. Sources of waste are domestic, industrial, and agricultural. Local governance bodies have the task of processing the quantum and variety of waste generated. This undertaking involves segregation, transport, composting, industrial processes related to recycling, energy recovery, treatment of hazardous wastes, and safe disposal. Policies to promote waste segregation at source are being articulated and implemented in various municipal regions and panchayats. Rules against the burning of garbage continue to be applicable, although not strictly enforced. Intermittent bans on materials that contribute to environment-degradation are implemented by local governance bodies, e.g., ban on the use of disposable plastic under the thickness of 40 microns by the Greater Hyderabad Municipal Corporation. Streamlined flows of segregated material from homes, and agricultural and industrial facilities, to composting and recycling units, would aid efficient energy recovery, and the better use of material, leaving little or no waste to be land filled. Water supply and sanitation services provided by the government include piped water supply and sewerage facilities. The following table reports sewerage facilities in the Greater Hyderabad Municipal Corporation area, and mentions sewage treatment plants, interception and diversion (I&D) structures, and conveying mains. Telangana ku Haritha Haram, the planting drive in the entire state was conducted in a mission mode recently. Its objective is to increase the green cover in the state, with an aim to plant 246 crore saplings. People from all walks of life, government agencies, officers, prominent citizens, and public representatives and school children are participants in the drive. In addition, there are regular campaigns for heat management, malaria, dengue and Chikungunya, etc., including dos and don'ts in the popular print and visual media. Government of Telangana is implementing the Aarogyasri Health Care Scheme. The objective of the scheme is the achievement of health coverage for BPL families in terms of financial protection and access to and quality health care. 80 to 85 % of the state population is covered under the scheme, there by poor BPL Families are being provided secondary and tertiary care treatment services, free of cost and have decreased the out of pocket expenditure to a great extent. The Table gives a summary of the district-wise count of therapies approved in the Aarogyasri scheme in

18 Table Food safety facilities and executives in Telangana FACT SHEET Telangana (Till ) 1 Food Safety Commissioner Shri B. Kishore IAS 2 Correspondence Address Commissioner of Food Safety (FAC) & Project Director, Aids control Society, DM&HS Campus, Sulthan Bazar, Koti, Hyderabad 3 Contact details Tel: Fax: kishore_jc@yahoo.com 4 Nodal Officer & Contact details Joint Food Controller Institute of Preventive Medicine Public Health Labs & Food (Health) Admin., Andhra Pradesh, Narayanguda, Hyderabad , Ph telanganacfs@gmail.com 5 Number of Districts 10 6 Number of DO 15 7 Number of AO 10 8 Number of FSO 20 9 Number of Food Analyst 8 10 Status of Public food Laboratories Total Number 1 State Food Lab, 1 Regional PH Lab Number of Functional Laboratories 11 NABL Laboratories in State Nil 12 Food Business Units licensed Food Business Units registered Steering Committee Yes 15 Tribunal Establishment No 32 Source: Fact Sheet Telangana, FSSAI. Available at: Table Sewerage facilities in the Greater Hyderabad Municipal Corporation area i) Sewage Treatment Plants: Amberpet 339 Mld Nagole 172 Mld Nallacheruvu 30 Mld Attapur 51 Mld I & D Structures 16 Nos (Location of I&Ds): Puranapool Pumping Stn., Puranapool, AfzalSagar, Patel Nagar, Puranapool South, Puranapool Part-II, Muslimjung, High Court, Saroornagr, MurkiNala, Ramanthapur, Surplus Nala, Bapughat, Mughalkanala, Bahadurpura, Golnaka ii) Conveying Mains Ramanthapur main 8 Km NIS main 4 Km SIS Main Pack Km SIS Main Pack2 4.3 Km SIS Main Pack3 5.2 Km Attapur Catchment 2.46 Km 413

19 Table District-wise count of Therapies approved under Arogyasri( ) The Government's national campaign, 'Swachh Bharat Abhiyan' (Clean India mission) aims to clean the streets, roads, and infrastructure in the cities and towns of India. Through 'Nirmal Bharat Abhiyan' (Total sanitation campaign), the Government aims to achieve 'open defecation free India' by 2019 and is committed to build toilets in villages, schools and other poor urban communities. Through 'Water, Sanitation and Hygiene' (WASH program) in schools, the Government promotes hand hygiene, availability of clean drinking water and sanitation apart from health education to children for general hygiene practices. These initiatives towards improving the sanitation and hygiene are likely to improve overall health of the communities and reduce the incidence of acute diarrhoeal diseases in the country. Comprehensive public health interventions like improvement in environmental sanitation, health promotion and preventive practices like use of clean drinking water are essential to reduce transmission of diarrhoeal diseases. Apart from active management against diarrhoea to prevent severe dehydration, management of malnutrition and micronutrient deficiency is required to reduce co-morbidity; and improvement in social determinants like poverty alleviation programs, education of women and girls are required for improving overall children's health and reducing diarrhoeal mortality Key challenges District There are several Government schemes that are helping in improving the health of the population. But there are several areas where there is an urgent need for health data. For example, there is a dearth of reliable data for some communicable diseases. A credible multi-site population based registry for Telangana would help fill the information gap, to inform policy, especially in areas like cancer. Data on the health effects of pollution is urgently needed. There is a need for standardized and district wise data on non-communicable or life-style diseases like stroke, hypertension, and diabetes: the cardiovascular condition is the number one cause of death due to the epidemiological transition that Telangana is undergoing. There is a large difference in the per capita availability of health workers between rural and urban areas, indicating the disadvantage of rural people interms of access to health services in general and public health services in particular. The rising cost of health care at the household level is a cause of concern and needs public action Recommended actions and good practices Improvement of the maintenance of data on disease incidence and public health indicators in both public and private health care facilities. Undertake health-environment correlation studies. Therapies Approved Count Adilabad 11,363 Hyderabad 34,420 Karimnagar 28,883 Khammam 15,790 Mahabubnagar 23,594 Medak 16,421 Nalgonda 26,659 Nizamabad 15,609 Ranga Reddy 30,531 Warangal 32,721 Grand Total 235,991 Source: Aarogyasri Healthcare Trust 414

20 Owing to inadequate public health facilities, while awareness and demand for health services are increasing, private health care has developed on a wide scale. Anaemia is high in Mahabubnagar. Necessary measures should be initiated to address it. Prevalence of Sickle cell Anaemia 80% of tribal people are anaemic in Adilabad. Have less haemoglobin due to malnutrition in children. Anaemia, T.B, Malaria, especially under women health issues should be addressed. Strengthening of obstetric services at PHCs, to facilitate safe deliveries, and a reduction in maternal and neonatal mortality rates. These should be addressed on priority. Awareness of hygiene, Healthy practices, sanitation and spread of communicable diseases. Alert System against Viral Infections and Water Pollution. Impart awareness about preventive measures. Better practices of Bio medical waste in rural and urban areas There is a need to concentrate on reduction of infant mortality rate (IMR). Special Focus is required on the Social Determinants of Maternal Health. Bibliography 1. World Health Organisation, Preventing disease through healthy environments: a global assessment of the burden of disease from environmental risks 2. Ministry Of Road Transport and Highways, Report of the Sub-Group on Policy Issues, Government of India. 3. National Crime Records Bureau, Ministry of Home Affairs. Government of India. Available from: 4. Kopits, E.; Cropper, ML. Traffic Fatalities and Economic Growth. World Bank Policy Research Working Paper No The Energy and Resources Institute. 2015; Available from: 6. Centre for Science and Environment. India's urban renewal plan goes wrong (CSE) Meshram II et al, Regional variation in the prevalence of overweight/obesity, hypertension and diabetes and their correlates among the adult rural population in India.Br J Nutr Apr 14;115(7): Epub 2016 Feb Jatav RK et al, A non-communicable disease, its prevalence in adult patients of Telangana region of South India; a semi-urban tertiarycare teaching hospital study. International Journal of Advances in MedicineApril-June2014Vol1, Issue SrinivasMadoori, Ramya C., ShashidharValugula, Sandeep G., SreenivasKotla Clinicohematological profile and outcome of anemia in children at tertiary care hospital, Karimnagar, Telangana, India.Int J Res Med Sci. 2015; 3(12): The district level household and facility survey-4, Ministry of Health and Family Welfare, Government of India Centre for Science and Environment, Centre for Science and Environment: Citizens' Report: Air Quality And Mobility Challenges In Hyderabad