by Eva A Rehfuess , Nigel Bruce and Jamie K Bartram

Modifiable environmental risk factors are responsible for approximately one quarter of the global burden of disease. This environmental burden of disease is distributed extremely unequally: in developing countries 15 times more healthy life years are lost per capita than in developed countries, with diarrhoea and acute lower respiratory infections among children being the largest contributors. The two principal environmental risk complexes for these diseases – drinking-water/sanitation/hygiene and indoor air pollution from solid fuel use – cause more than 2 million deaths annually.1

Known effective solutions include: ensuring that households have access to and use safe drinking-water and improved sanitation facilities; encouraging household water treatment; promoting the use of cleaner-burning stoves and switching from traditional solid fuels to cleaner modern fuels.2,3 They are good value for money, yielding health-care savings, health-related productivity gains, time savings and environmental benefits that far exceed costs.

Delivery of environmental health interventions is, however, rarely administered or controlled directly by the health sector. Uncertainty about leadership and responsibilities across many public and private actors contributes to overall underperformance and inefficiency. This raises important questions about the most appropriate and effective roles for the health sector in environmental health policy development and implementation. We believe that, to date, attempts to answer these questions, conceptually or in practice, have been limited but will be essential if we want to make use of a significant opportunity to reduce the disease burden attributable to the environment, especially in developing countries.

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