Astrid Fossier-Heckmann et Hugo Tiffou • Groupe santé-environnement de Médecins du Monde
Linking environment and health is not obvious for many humanitarian NGOs. Médecins du Monde has managed to make this theme one of its priorities. A look at a fight that, backed up by the right to health, could join forces with the fight against the effects of climate change.
Over the summer 2019, a number of Asian countries decided to start sending back to their senders dangerous waste illegally imported from “Northern” countries(1)First China, and then the Philippines, Malaysia, Indonesia and Sri Lanka sent waste back to Canada, the United States, the United Kingdom, France, Germany, Australia and even to Hong Kong https://www.la-croix.com/Monde/Asie-et-Oceanie/LAsie-veut-etre-depotoir-lOccident-2019-08-04-1201039287. In the shadow of these containers of shame, whole communities are indeed living from recycling other countries’ unwanted waste, and this for many years. At the risk of contracting different pathologies, even of dying. Like their governments, which are finally taking action to put an end to this trade in toxic products, these communities are beginning to appreciate the dangers to which they are exposed and are seeking solutions to protect themselves. In Manila (Philippines) and Kathmandu (Nepal), Médecins du Monde (Doctors of the World/MdM) is working with people from the informal recycling sector to reduce the risks associated with their work and to denounce, together, the health inequalities suffered by this vulnerable and stigmatised group.
As the fight against the effects of global warming that mobilizes more and more humanitarian and development NGOs(2)See the previous issue of our review, Humanitarian Alternatives, “Climate change: understanding, anticipating, adapting”, Nº.11, July 2019, https://alternatives-humanitaires.org/en/eleventh-issue-july-2019, environmental issues are becoming an increasingly important topic of discussion both within and between associations. Since 2015, at MdM France, health and environment has been one of our organisation’s priority areas of intervention – alongside rights and migration, risk reduction, sexual and reproductive health and crisis response – and has been opened a gap in the practices of the association. Indeed, although environmental health offers us a new way of looking at the needs of already vulnerable populations whose vulnerability is heightened by their environment, it also challenges our preconceptions about the role humanitarian NGOs should be playing in this field, especially an activitst medical NGO like MdM. Can working on the physical environment be considered medical intervention? Do our attempts to make it less harmful compromise our political fight against the very existence of this environment and the social inequalities that underpin it?
In this article, we have sought to explain why environmental health became a priority for MdM and how, over the last five years, we have developed new knowledge, know-how and attitudes.
First environmental steps of a medical NGO
Although very much in the forefront in these times of global warming, consideration of the impact of the environment on health is nothing new. A very quick look at ancient and more recent history should be enough to convince you of this. In the 5th century BC already, Hippocrates, in his treaty On Airs, Waters and Places, believed that “whoever wishes to properly pursue the science of medicine ought first to consider the seasons, the winds and the properties of the waters, and study the soils and the mode of life of the inhabitants”. In the 19th century, public health in Europe developed as a result of the links established between infectious diseases and environmental studies, as in John Snow’s work on cholera in London. Today, science has confirmed the relationship between harmful environments and chronic diseases, as well as the influence of environmental factors on the aetiology of certain cancers, neurological and degenerative diseases, etc.
MdM’s first health & environment activities were in Paris back in 1993, when it launched action to protect vulnerable children from lead poisoning. Despite being made a national priority at the end of the 1980s, the only monitoring of lead poisoning by the authorities was statistical. Children at risk were tested, but their lead levels were never noted in their medical records – a way of ensuring nothing had to be done about a problem for which no resources had been made available. So the costs of reducing exposure were cynically avoided. In fact, rather than acknowledge the impact of the environment on people’s health, the people themselves were blamed, sometimes in extremely discriminatory and even racist terms. The real cause of the problem was allegedly the families’ “practices”. In Paris, a group of MdM voluntary workers, outraged by the inaction, decided – with the families concerned – to ensure the protection of these children themselves through renovation works, rehousing and advocacy. After the publication of a revealing report in 1997, a lead poisoning action plan was incorporated into the French law of 29 July 1998 against exclusion. The authorities had opened their eyes at last. But although this was a major step forward for the families concerned and for MdM, it was only the beginning of the story. The families formed an association and took their case to court where the City of Paris was found guilty of failing to take appropriate action. Responsibility was no longer attributed to the families but to their environment and to those who, despite having full knowledge of the facts, left them to live in it.
These events of 20 years ago marked the beginnings of a certain modus operandi for MdM with respect to environmental health that combined a denunciation of harmful living environments and a refusal of stigmatisation with risk reduction, community mobilisation and lobbying the authorities.
The same impetus drove MdM to launch actions around, in particular, the question of nuclear weapons testing and landmines in Mururoa (French Polynesia) in 2002, before going abroad, in Bolivia in 2006 and Niger in 2009. However concerns are emerging within the organisation about the legitimacy of a medical NGO to address these issues. A Health & Environment group was officially set up in 2010 to structure debate, form alliances and develop advocacy.
The time of structuring
The Health & Environment group set out to prove that “harmful” environments are not a secondary factor, but rather a major health determinant, almost always linked to social and economic vulnerability. However, the range and diversity of environmental risks, difficulties in measuring exposure and a lack of internal expertise complicate the transition from intuition, which was certainly well-supported, to formal proof.
From 2012 to 2017, a programme on the health risks linked to the dismantling of electronic waste in Manila made health & environment issues more visible, which helped increase internal buy-in. During the same period, in France, action was structured on substandard housing issues within the Collectif des Associations Unies Contre le Mal Logement (CAU). Through these programmes, MdM notes that the social gradient in health is exacerbated by the daily exposure of populations to toxic agents in their living and working environments. These communities were also seen to have reduced access to prevention and care as well as to information that would help them limit the risks for themselves and those around them. Exposure to harmful environments was found to interact with other health determinants, heightening existing social and geographic inequalities and increasing further the vulnerability of these groups.
Thus, in 2015, on the basis of concurring observations in France and abroad and given the absence of any response and the clear need to challenge the authorities on these environmental factors that cause harm to human health, MdM decided to make health & environment its fifth priority area of intervention. In 2017 MdM developed a strategic intervention framework and in 2018 a resource person was recruited at the headquarters.
Transforming indignation into action
MdM’s intervention strategy is built on four pillars: identification and reduction of the risk factors related to the environment; prevention, detection and access to treatment of the diseases caused by harmful environments; the promotion of social change by helping to empower individuals and communities to create healthier living environments; and finally advocacy for combating health and environment inequalities and building durable alliances.
In order to develop knowledge and know-how suited to the needs in the field and without losing touch with the multitude of contexts and environmental factors liable to affect health, MdM decided to concentrate on exposure to harmful environments in the places where people live (with a particular focus on slums) and work (initially work with waste but, in the future, extraction of natural resources and pesticides). Currently running projects are in Manila, Kathmandu, Mayotte, Bordeaux and Marseille, and explorations are underway elsewhere in Asia, in Africa and in France.
Health promotion and harm reduction
In the field, MdM’s core activity is required: the health promotion approach helps to strengthen the communities’ capacity to act, with the aim of challenging and bringing about legal and social change. However, to be effective, it is essential to have a non-judgemental approach to at-risk practices.
Although the rationale behind these interventions has proven its effectiveness, especially in the Philippines, it has also sparked debate within MdM. Improving living conditions in slums has been a topic for discussion. Isn’t there a danger that this could undermine MdM’s firm stance on the need to reduce slum-dwelling? Isn’t this providing the authorities with an excuse to carry on ignoring the unacceptable living conditions in slums because they have become slightly less deplorable? With environmental NGOs, too, the issue of risk reduction is a point of tension. In Manila, MdM cannot align itself with those NGOs understandably demanding a ban on the informal dismantling of electronic waste. MdM has adopted a pragmatic approach of promoting the accompaniment of dismantling practices to reduce risks to health. If it is not to be perceived as weak or myopic, this approach of reducing the harm caused by exposure must be accompanied by long-term advocacy for the reduction of social and health inequalities due to the toxicity of certain environments.
Forming alliances to inform communities
In order to find objective evidence of the links between harmful environments and health to support advocacy actions, it is necessary to form alliances with the world of research, in which MdM would play an active role of go-between with marginalised populations. Thus, in Nepal in 2018, MdM joined forces with the English University of Sheffield to carry out a cross-sectional study(3)M. Black et al., “The health risks of informal waste workers in the Kathmandu Valley: a cross-sectional survey”, Public Health, 166, January 2019, p.10-18, https://www.ncbi.nlm.nih.gov/pubmed/30419409and https://www.youtube.com/watch?v=s8Kh8y7UjVM&t=311s with 1,300 people in the Kathmandu valley, the largest sample of informal waste workers ever interviewed. MdM facilitated access to this highly stigmatised population, while Sheffield drew up the study protocol, obtained approval from the appropriate ethical committees and collected and analysed data. The data gathered in the study was shared by means of a data party, a participatory process which enabled the workers to take ownership of the data concerning them and play an active role in analysing it. The findings of this study are now being used to demonstrate to local and international authorities the impact on workers’ health of stigmatisation, highly precarious living conditions and non-recognition of the harmful risks involved in informal waste collection. In 2019, MdM’s Health & Environment programmes have been the focus of a number of written and oral communications and round-tables at international seminars.(4)31st annual conference of the International Society for Environmental Epidemiology (ISEE 2019), 25-28 août 2019, Utrecht (Netherlands), https://isee2019.org/venue; Humanitarian Summit, Berlin (Germany), 17-18 oct. 2019, https://10times.com/humanitarian-congress; 16th International Conference on Urban Health (ISUH 2019), 4-8 November 2019, Xiamen (China), https://isuh.org/conference/xiamen-2019
Thus, little by little, thanks to the advances made through our research and actions in the field, Health & Environment was structured within the NGO. And by joining international networks, such as Health Care without Harm, International Society for Doctors of the Environment and the Health and Environment Alliance, the Health & Environment group continued to support its development through the ongoing monitoring and review of our intervention strategy in France and abroad.
Wondering about one’s own practices and the need for clean practices
Working on harmful living and working conditions with the most vulnerable populations requires, almost ethically, that MdM takes a look at its own environmental practices. First of all, MdM has launched an environmentally-responsible approach to reduce its own carbon footprint (medical waste management, transport use, etc.) and the risks associated with natural disasters in its projects, starting in Asia where 80% of the world’s disasters occur, and also in Madagascar and Haiti.
We are also exploring other possibilities for citizen engagement in a broader movement against global warming, for example by sharing the data collected through our programmes and by illustrating the impact of climate change on the health of the most marginalised communities – migrants, informal and seasonal workers, people living in squats and slums and homeless people – with which MdM has been working closely for many years.
We believe that, in France and abroad, for both our beneficiaries and our staff, the environment can and must be seen as an “extension of the field of health”, to use Boris Martin’s expression in an article he wrote on electronic waste recyclers in Manila for Humanitaire review(5)Boris Martin, « Recycleurs de Manille : la santé comme moteur du changement »,Humanitaire, 12 septembre 2014, https://journals.openedition.org/humanitaire/2974. Because it is only by listening to what the people concerned have to say, and by fighting for social change, that we will be able, from local to global level, to reconcile health and environment.
Translated from the French by Mandy Duret
Astrid Fossier-Heckmann • She has been with MdM since 2003 and has worked on different humanitarian aid programmes in Asia and Africa. Astrid notably coordinated MdM’s E-waste programme in Manila. She is now the volunteer board delegate for MdM’s Health Waste Workers project in Nepal and coordinates the organisation’s Health & Environment group with Hugo Tiffou.
Hugo Tiffou • He worked in the field of humanitarian aid for 19 years. He represented MdM in the Collectif des Associations Unies (CAU) and contributed to the organisation’s lesson-learning from the e-waste programme in Manilla (Philippines). He is still involved in primary health care and health promotion as director of AVECSanté (www.avecsante.fr) and maintains his links with MdM on Health & Environment issues, with Osiris health centre in Marseille and the Association Communautaire Santé Bien-Être in Saint Denis.
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|￪1||First China, and then the Philippines, Malaysia, Indonesia and Sri Lanka sent waste back to Canada, the United States, the United Kingdom, France, Germany, Australia and even to Hong Kong https://www.la-croix.com/Monde/Asie-et-Oceanie/LAsie-veut-etre-depotoir-lOccident-2019-08-04-1201039287|
|￪2||See the previous issue of our review, Humanitarian Alternatives, “Climate change: understanding, anticipating, adapting”, Nº.11, July 2019, https://alternatives-humanitaires.org/en/eleventh-issue-july-2019|
|￪3||M. Black et al., “The health risks of informal waste workers in the Kathmandu Valley: a cross-sectional survey”, Public Health, 166, January 2019, p.10-18, https://www.ncbi.nlm.nih.gov/pubmed/30419409and https://www.youtube.com/watch?v=s8Kh8y7UjVM&t=311s|
|￪4||31st annual conference of the International Society for Environmental Epidemiology (ISEE 2019), 25-28 août 2019, Utrecht (Netherlands), https://isee2019.org/venue; Humanitarian Summit, Berlin (Germany), 17-18 oct. 2019, https://10times.com/humanitarian-congress; 16th International Conference on Urban Health (ISUH 2019), 4-8 November 2019, Xiamen (China), https://isuh.org/conference/xiamen-2019|
|￪5||Boris Martin, « Recycleurs de Manille : la santé comme moteur du changement »,Humanitaire, 12 septembre 2014, https://journals.openedition.org/humanitaire/2974|