DETERMINAN KESEHATAN

Determinan Lingkungan

Nunuk Nugrohowati
Dept. of Public Health & Preventive Medicine
 Learning Objective:
Mampu memahami prinsip dasar kesehatan
lingkungan (Environmental Health)
Dasar ekologi dan kesehatan
Mampu memahami patofisiologis penyakit akibat
lingkungan
Agent infeksius, Kimia toksik, serat, debu dan radiasi di
lingkungan
Masalah psiko-sosial di masyarakat
route of exposure
Mampu memahami perubahan iklim global dan
dampaknya pada kesehatan
 Referensi

Yassi A, Kjellstrm T, de Kok T, Guidotti TL. Basic

environmental health. New York: Oxford University
Press, 2001
Smith KR, Corvaln CF, Kjellstrm T. How much
global ill health is attributable to environmental
factors? Epidemiology, September 1999, Vol.
10(5):573-84
Last J.M. Public Health and Human Ecology.
Chapter 4: Environmental Health. McGraw-Hill Med
Publishing Co, 1998
Blumenthal and Ruttenber. Environmental Health.
2nd edition, Springer Publishing Co, 1995
 DETERMINAN KESEHATAN
Untuk mewujudkan keadaan sehat, ada empat
determinan utama yang perlu diperhatikan
(Blum, 1974);
1. Perilaku
Kebiasaan atau gaya hidup sehari-hari yang
diperlihatkan seseorang
2. Lingkungan
Keadaan sekitar dalam bentuk lingkungan fisik dan
lingkungan non fisik yang berinteraksi dan
mempengaruhi kesehatan seseorang

4
 DETERMINAN KESEHATAN

3. Pelayanan kesehatan
Akses, keterjangkauan dan mutu pelayanan
kesehatan yang tersedia di masyarakat
4. Keturunan
Kualitas dan kuantitas genetik yang bersifat
diturunkan

5
 LINGKUNGAN

PELAYANAN
PERILAKU SEHAT
KESEHATAN

KETURUNAN

6
 PRINSIP DASAR KESEHATAN
LINGKUNGAN
BIRTH, LIFE, DEATH & THE ENVIRONMENT

Mahluk yg hidup pertama kali menghadapi lingk

keras shorter life expectancy
U/bertahan mereka harus:
Bertahan dg mencari makan & minum
sementara hrs menjaga hutan thd kerusakan
Peny infeksi & parasites menyebar dr orang-
orang, hewan-orang, mel makanan, air minum
atau hewan vektor
Kelukaan dr jatuh, api, serangan hewan
Suhu dingin, panas, hujan, salju, bencana dll
Blums Theory (1974):
Apa itu lingkungan (environment) ?

(all) that which is external to the individual human

host. (It) can be divided into physical, biological,
social, cultural, any or all of which can influence
health status in populations (Last, 1995)
Lingk menyebabkan bbrp peny yang bukan
berasal dari genetik
Faktor lingk termasuk semua hal yg
mempengaruhi organisme stlh konsepsi baik
mel kondisi sosial tertentu/pilihan masing2
individu melalui media lingkungan
 Environmental Health
comprises those aspects of human health,
including quality of life, that are determined
by physical, biological, social and
psychosocial factors in the environment
refers to the theory & practice of assessing,
correcting, controlling, & preventing those factors
in the environment that can potentially affect
adversely the health of present & future
generations
WHO, 1993
 Environmental Health Science

hazards in the environment, their

effects on health & the variations in
sensitivity to exposures within
populations
development of effective means to
protect against hazards in the
environment
 Ecosystem
any spatial or organizational unit which
includes living organisms & nonliving
substances interacting to produce
exchange of materials b/w the living &
nonliving parts

Basic components:
abiotic substances
producer organisms
consumer organisms
decomposer organisms
Basic components of an ecosystem
PRODUCERS
Green plants
Bacteria

PRIMARY CONSUMERS
Basic plant Herbivores
nutrients Plant parasites

SECONDARY CONSUMERS
DECOMPOSERS Omnivores
Saprophytic bacteria Carnivores
Fungi Animal parasites
Scavengers
Simplified illustration of integration within the
comparatively simple pine forest ecosystem
 Patofisiologis penyakit akibat
lingkungan
Terjadinya agent lingkungan berdasar atas
kejadian2 al;
nature
natural vs anthropogenic
traditional vs modern
route of exposure
setting
Manusia memp kemamp lebih utk beradaptasi,
mempeng lingk mereka u/memenuhi keinginan
nya banyak cara u/membuat lingk leb sehat
Bbrp gangg pd kes lingk yg seharusnya bs diatasi
o/ setiap individu a.l:
Polusi industri
Penyediaan yg kurang baik pd air minum dan
sanitasi
Perumahan & tata kota yg buruk
Kurang kontrol pd penyediaan mknan/ industri
mknan
Kualitas jalan yg tdk baik
Kondisi yg tdk nyaman ditempat kerja
Agent Traditional
Disease vectors
Infectious agents
Inadequate housing &
shelter
Poor-quality drinking water
& sanitation
Indoor air pollution from
cooking
Dietary deficiencies
Hazards of child birth
Wildlife & domestic
animals
Injury hazards in
agriculture
Agent Modern
Tobacco smoking
Transport hazards
Pollution from sewage &
industry
Outdoor air pollution from
industry & motorcars
Overuse or misuse of
chemicals
Industrial machinery
Unbalanced diet
Route of exposures
Source:
natural events
man-made: industrial, agricultural,
commercial, domestic, manufacturing wastes
Exposure:
- inhalation - breastfeeding
- oral ingestion - placental transfer
- absorption via the skin - inoculation & direct
penetration
- absorption via the eyes
 Air, water, Food, water,
Exposure Air
dirt, etc drugs
Media
inhalation exhalation ingestion

Major uptake Respiratory

pathways Skin GI-tract
tract

bile
exfoliation

Transport & Other

distribution organs
Blood Liver

Kidney

Major
excretory Sweat Hair Urine Faeces
pathways

external contamination
 Tipe agent pada kesehatan lingkungan
Agent Biologi
e.g. bacteria, viruses, parasites
Agent kimia
e.g. toxic metals, air pollutants, solvents, pesticides
Agent fisika
e.g. radiation, temperature, noise
Agent Mekanik
e.g. motor vehicle, sports, home, agriculture, & workplace
injury hazards
Agent Psikososial
e.g. stress, lifestyle disruption, workplace discrimination,
effects of social change, marginalization, unemployment
 Bacteria
AGENT BIOLOGI
plants, insects, rodents, other animals,
fungi, bacterial, viruses, protozoa, a wide
variety of toxins & allergens; & prion
Routes of exposure:
Air
Water
Food
Direct penetration
Biting
Seseorang terpapar agent didistribusi via darah,
lympha/body fluids lain ke bag tubuh yg nyaman
utk berkembang biak
 Pathway Disease
Inadequate sanitation, the dumping of cholera, typhoid fever, dysentry, other
untreated sewage into surface water, diarrheal diseases, hepatitis A,
schistosomiasis
poor hygienic practices water
polluted by human excreta
Overcrowding, poorly ventilated tuberculosis, measles, influenza,
housing airborne transmission pneumonia, pertussis, cerebrospinal
meningitis
Unhygienic animal husbandry plague & hydatids diseases
zoonoses transmission
Stagnant waters, unsanitary housing, malaria, trachoma, schistosomiasis,
refuse dumping vector-borne filariasis, yellow fever, plague, typhus,
trypanosomiasis
transmission
 AGENT KIMIA

Inorganic Substances
- halogens (e.g. fluorine, chlorine, bromine, iodine)
- alkaline compounds (e.g. NH3, Ca(OH)2, KOH, NaOH
- ozone (O3)
- NOx and SOx
- metals (e.g. cadmium, chromium, copper, lead,
manganese, mercury, nickel, arsenic)
Organic Compounds
- aliphatic hydrocarbons (e.g. methane, ethane,
propane, butane, pentane, hexane, heptane,
octane)
- alicyclic hydrocarbons (e.g. cyclohexane,
methylcyclohexane, turpentine)
- aromatic hydrocarbons (e.g. benzene, toluene,
styrene, naphthalene)
- halogenated hydrocarbons (e.g. chloromethane,
dichloromethane, chloroform, carbon tetrachloride,
trichloroethyene, polyviyl chloride)
- alcohols (e.g. methanol, ethanol, propanol)
 AGENT FISIKA

Bentuk2 energi yg sec potensial mengganggu di lingk yg

menimb gangguan/kerusakan immediate atau gradual apbl
di transfer dlm juml yg cukup utk mencemari seseorang
e.g.: sound waves, radiation, light energy, thermal energy,
electrical energy
 AGENT MEKANIS

Dengan cara mentransfer energi mekanis atau

kinetik (the energy of motion)
Injury, trauma, accidents

Vulnerable groups:
children, the elderly, & disadvantaged groups
 AGENT PSIKOSOSIAL
Sumber potensial yang menimbulkan stress
psikososial :
- factors intrinsic to the job
- the role of the worker in the
organization
- career development
- interpersonal relationships at work
- organizational structure & climate
 Biological, chemical & physical hazards
by routes of exposure
Routes of
Biological Chemical Physical
exposure
AIR
Agent/source Microorganisms Fumes, dust, particles Radiation, heat, noise

Vectorial factors Coughing, exhalations Contaminated air Climate, unguarded

exposures
Routes Inhalation, contact Inhalation, contact Inhalation, direct
penetration
WATER
Agent/source Microorganisms, Discharges, teaching, Radiation, heat in power
decayed organic dumping station cooling water
material
Vectorial factors Insects, rodents, snails, Contaminated food & Accidents,
animal excreta, food water contaminated food &
chain water
Routes Bites, ingestion, contact Ingestion, contact Ingestion, contact
 Cerebral edema in lead
poisoning
The gyri are flattened
and widened, the sulci
are narrowed and
relatively
inapparent
 The scale & nature of human activities
(agricultural, industrial, & energy production, the use &
management of water & wastes; urbanization; the
distribution of income & assets within & between countries;
the quality of health services; & the extent of protection of
the living, working, & natural environment

HEALTH

Physical & chemical environment

Biological environment
(air, water, food & soil chemical composition
(type & distribution of pathogens & vectors, as
including radiation; climate including temperature,
well as their habitats)
humidity, precipitation, & seasonal changes)

Source: Yassi et al., 2001 (adapted from WHO 1992)

 Sustainable Development

development that meets the needs of the

present without compromising the ability of
future generations to meet their own needs
(WCED, 1987)
Human beings are at the center of concerns for
sustainable development. They are entitled
to a healthy & productive life in harmony with
nature
 UN:
1st Order Principle:
Ensuring human survival should be
taken as a first-order principle
Universal Declaration of Human Rights (UN, 1948)
all people have the right to a standard of living adequate
for the health and well-being of themselves & their family,
including food, clothing, housing, health care, and the
necessary social services

2nd Order Principle:

Respect for nature & control of environmental
degradation
 Syarat dasar untuk sebuah
lingkungan yang sehat
Udara bersih
Air yang cukup dan aman
Makananan yang cukup dan aman
Perumahan yang aman dan nyaman
Lingkungan global yang stabil
 Metode pengukuran

Environmental Human Health

Quality Exposure Impact
Monitoring Monitoring Assessment
 RISK MANAGEMENT
Environmental health indikator:
1. Environmental measurement Risk Assessment

Quantitative Risk Assessment (NRC, 1983):

Hazard identification is there a hazard? Study
literature
Dose-response what is the relationship b/w
exposure or dose & risk? Study literature
Exposure assessment what is the distribution of
exposure? Person, time, place
Risk characterization what is the risk to the
population? Expose vs min expose people
2. Human measurement environmental epidemiology

Environmental epidemiology:
Sampling design for human
Measurement outcome
PEM (Personal Exposure Measurement)
Biomarkers
Health status
Death
Exposure metrics in environmental
epidemiology

Cumulative exposure
Exposure during a susceptibility window
Recent exposure
Time since first exposure
Age at first exposure
Exposure rate
Peak exposure
Exposure above threshold
 THE PATHWAYS FROM SOURCES & MEDIA OF EXPOSURE TO
HEALTH EFFECTS (NRC, 1991)
Air Water Soil Food

Media of exposure source

Transport & fate

Inhalation
Routes of
Ingestion
entry Skin

Exposure
Physicopharmacokinetic Environmental epidemiology
models

Applications
Internal dose Risk assessment

Risk management

Biologically effective dose

Intervention, prevention &
Pharmacodynamics
diagnosis
models
Health & comfort effects
 Perubahan iklim global dan
dampaknya pd kes
GLOBAL
CHANGES NEGATIVE, e.g.:
POSITIVE, e.g.: Ozone depletion
Improved The greenhouse effect
communication Deforestation &
Expanding desertification
trade Loss of biodiversity
Introduction of Interregional transport
new of pollution
technologies Large scale of
resource depletion

Copyright 1996-98 Dale Carnegie & Associates, Inc.

Stabilitas ekosistem : Dasar Kesehatan
Manusia
Masalah kes lingk disebabkan o/ :
direct impact of pollutant kes manusia
indirect impact of pollutant by damaging
stable ecosystem mengurangi produktivitas
membahayakan kes mns
Mis deforestation (pembalakan liar), clear land
(pembakaran hutan), extensive urbanization;
Hal2 yg terjadi adalah:
- aliran air sungai meny banjir, menurunk
produk pertanian, mengganggu ketersediaan air
yg akhirnya meny berkemb peny infeksi
- meningkatkan pemanasan global CO2
Gangguan thd lingk yg lain adl:

Desertification
Loss of biodiversity
Acid precipitation
Trans-boundary movement of hazardous
waste
Natural & technological disasters
Masalah degradasi lingk menjd global dg
timbulnya 3 persoalan:

Adanya imbalance pada tingk sistem global, mis

: iklim
Adanya distribusi masalah lingk yg nyata mis:
polusi udara menjd leb luas &antar neg sampai
mslh ini dpt diatasi sec global
Sistem ekonomi & politik yang meny masalah
menjd global dimana dunia cepat menjd
ekonomi pasar yg besar
Lapisan ozon di atmosfer
 THE GREENHOUSE EFFECT
Radiasi infrared sampai ke atmosphere
Atmosphere menginsulasi panas ketika
radiasi infrared di absorbsi
CO2, uap air & gas2 yg lain memerangkap
panas
 OZONE DEPLETION & UV
RADIATION
Stratosphere: O2 + UV O3 (akumulasi terus
menerus u/mengabsorb radiasi UV berlaku sbg
pelind permukaan bumi dr paparan yg leb besar
UV-A, UV-B, UV-C
Tingkat lap Ozone di stratosphere yg menurun
dibbrp tempat mis: kutub utara & selatan
Peranan CFCs:melepas chlorine dg photolysis.
chlorine bebas akan merusak ozone (1 to
10,000)
Sumber CFCs : industri, refrigeration, AC,
aerosols as propellants
Half-life: > 75 tahun
 DAMPAK POTENSIAL DARI
PERUBAHAN IKLIM
Heat stress
Bencana alam krn perub iklim
Distribusi Vector
Kekurangan makanan
Banjir
Dampak ozone depletion thd kes
manusia
Non-melanoma skin cancer, mis.
Squamous Cell Ca & actinic keratitis
Malignant melanoma
Cataract
Degenerasi Retinal
Impaired immunological responses
Accelerated aging of skin
Pterygia
 Climate Change and health
Health Effects
Modulating
-Temperature-related
influences
illness and death
-Extreme weather-related
Regional
Microbial health effects
Weather
Contamination -Air pollution-related
Changes
pathways health effects
Heatwaves
Transmission -Water and food-
Extreme
dynamics borne diseases
CLIMATE weather
Agro-ecosyst, -Vector-borne and
CHANGE Temperature
hydrology rodent-borne
Precipitation
diseases
Socioeconomics
-Effects of food &
demographics
water shortage
-Mental, nutritional,
Health-specific inf & other health effects
RESEARCH Adaptation meas
Evaluation of
NEEDS
adaptation
Thank you .