REPORT NO. P5-3

LEAD PROGRAMME IN TECHNOLOGIES FOR ENHANCED ENVIRONMENTAL MANAGEMENT

OUTPUT TRACKING SHEET Project Phase: Phase 5 Title: Cato Manor Health and Environment

Report

Author: Liz Thomas (MRC) Version: Final version Reviewer: Michelle Binedell (CSIR) Date of finalisation: January 2001 Referenced as: Thomas,L.(2001). Cato Manor Health and

Environment Report. LEAD Programme

in Technologies for Enhanced

Environmental Management. Durban,

January.2001.

Sign-off:………………………………… Project manager

THE LEAD PROGRAMME IS FUNDED BY THE DEPARTMENT OF ARTS, CULTURE, SCIENCE AND TECHNOLOGY

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FINAL VERSION

CATO MAN0R HEALTH AND ENVIRONMENT REPORT

For CSIR Environmentek Lead Programme in Technologies for Enhanced Environmental Management

Prepared by Liz Thomas Health and Development Medical Research Council ethomas@mrc.ac.za

17 JANUARY 2001

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EXECUTIVE SUMMARY Cato Manor is a well-located extensive (9000ha) swathe of land in Durban that stood largely vacant during the 1970s and 1980s as a result of the forced removal of previous residents under apartheid. The 1990s has seen the rapid development of the area both through informal land invasions as well as formal housing development under the auspices of the Cato Manor Development Association (CMDA). The CMDA’s approach encompasses the delivery of housing, educational, social, housing, human and economic development in an integrated manner. The current population stands at nearly 100 000 with the ultimate mixed-use development being designed to accommodate 150 000 lower income people and 25 000 permanent jobs. The current population is heterogeneous with certain precincts accommodating wealthier households in formal housing and some of the poorest communities being located in informal settlements. The informal areas have access to the lowest levels of basic services. In 1996, approximately half of all the residents of Cato Manor relied on shared water supplies and non-flush sanitation systems. The second half of the 1990s saw considerable investment in water tanks on each site in certain areas, however in 2000, a large percentage of the population still relies on rudimentary water and sanitation services. Outbreaks of shigella and cholera have occurred in the past two years. The area has been subjected to extensive inappropriate dumping of waste and many of the open space areas and watercourses are heavily polluted. Although the local municipality does provide a refuse collection system, this is not seen to be satisfactory and viewed as a potential cause of disease by some of the residents. The households living in informal areas rely largely on paraffin (kerosene) as the locally preferred non-electrical fuel source. Cooking occurs indoors. From a small-scale study there are indications that there may be problems of inadequate ventilation due to people not opening windows, in part due to security concerns. Overall, those living in informal areas appear to face multiple health risks associated with the low level of services available to them and the difficulty experienced by emergency services in providing timely services due to the high density housing. The views of residents occupying recently constructed formal housing points to problems with the design and construction that are not always health-promoting. Problems with the size of structure, orientation, ventilation, damp and the disposal of sullage were highlighted by some, as cause for concern. The area is served by a number of community facilities and more are in the planning stage. A Community health centre is proposed, which will be a multi-purpose comprehensive facility. While funding has been secured for its construction, the commitment to the running costs has not been finalised yet with the local council. Clinic data from the main health facility in the area, the Ekhupeleni Clinic was assessed. The main problems that people came to the clinic to seek treatment for were skin complaints, upper respiratory conditions and ear, nose and throat problems. These were consistently high over the review period. For children (under15s) gastro

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intestinal problems were also of note. All of these conditions can be linked to environmental health factors. The review was not able to establish causal links between the health conditions and the quality of the environment due to the health data being case-based and the exposure data being spatially-based. The clinic data however shows the top health problems being potentially linked to environmental conditions. Health-risk exposures can be reduced through health education, but most of the problems need to be addressed through development programmes. These must include addressing the underlying poverty though job creation, training etc as well as the provision of basic services. The current stage of development and integrated approach adopted by the CMDA, provides an opportunity for innovation and partnerships between community, development and social agencies in exploring how the need for basic services can be met in the most cost effective and health-promoting way. The review concludes with an evaluation of a framework of core environment and health developed in Alexandra. The assessment finds that data on the core indictors was not available for Cato Manor, contrary to expectations in view of the sophisticated development programme underway. It suggests that a less ambitious set of environment and health indicators may be more appropriate for typical state of the environment and health reviews.

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LIST OF FIGURES AND TABLES Figure 1 Aerial location of Cato Manor: photo 2

TABLE OF CONTENTS

Executive summary

List of figures and tables Acknowledgements 1. Introduction 1

1.1. Background to the study 1 1.2. Methodology 1 1.3. Overview of Cato Manor 2 1.4. Historical development 2 1.5. Current developments 2 1.6. Housing 4 1.7. Other developments 4 1.8. Future challenges 4 1.9. Key issues 5

2. Socio-economic profile 6

2.1. Introduction 6 2.2. Population profile 6 2.3. Age and sex profile 6 2.4. Educational profile 6 2.5. Employment profile 9 2.6. Key findings 11

3. Living environment 12

3.1. Introduction 12 3.2. Cato Manor living environment 12 3.3. Access to basic services 14 3.4. Water 15 3.5. Sanitation 18 3.6. Refuse removal and waste services 20 3.7. Access to electricity 22 3.8. Access to telephones 25 3.9. Housing 25 3.10. Emergency services 28 3.11. Community facilities 29 3.12. Health services 29

4. Health profile 32

4.1. Introduction 32 4.2. Visits to the clinic 32 4.3. Main reason for visit to clinic 32 4.4. Data constraints 35 4.5. Environmental health services 35 4.6. Concluding comments 36

5. Health Exposures and responses 37

5.1. Overview: Health and environment context and linkages Visits to the clinic 37 5.2. Cato Manor Overview 37 5.3. Urban environmental factors and potential responses 40 5.4. Concluding comments 42

6. Assessment of the Alexandra Framework and discussion about data collection 44 6.1. Environment and health indicators developed for Alexandra 44 6.2. Assessment of the Alexandra framework 44 6.3. Additional indicators 46 6.4. Data problems 46 6.5. Concluding comments 48

References 49

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Figure 2 Old Cato Manor circa 1950: photo 2 Figure 3 Precincts: map 3 Figure 4 Population density: map 7 Figure 5 Age-sex pyramid: Cato Manor 8 Figure 6 Male by age comparisons for Cato Manor, Cato Crest and South

Africa 8

Figure 7 Employment status: pie diagram 9 Figure 8 Unemployment: map 10 Figure 9 Population by suburb: pie diagram 13 Figure 10 Type of housing: graph 13 Figure 11 Access to basic services in suburbs in Cato Manor: table 15 Figure 12 Access to water (1996): map 16 Figure 13 Water collection: photo 17 Figure 14 Water tank: photo 17 Figure 15 Access to sanitation (1996): map 19 Figure 16 Pit toilet: photo 20 Figure 17 Refuse bag use: photo 20 Figure 18 Access to refuse services (1996):map 21 Figure 19 Dumping in a water course: photo 22 Figure 20 Access to electricity (1996):map 23 Figure 21 House expansion: photo 26 Figure 22 Construction problem - roof/ wall interface: photo 26 Figure 23 Construction problem - subsequent addition of air bricks: photo 26 Figure 24 Damp south facing wall: photo 27 Figure 25 Informal protection from run off and standing water: photo 27 Figure 26 Health services - Ekupheleni clinic: photo 29 Figure 27 Private health services: photo 30 Figure 28 Albert Luthuli Metropolitan Hospital: photo 31 Figure 29 Main complaints by those attending the clinic during 2000 33 Figure 30 Change in share of cases over two time periods 1988-2000 34 Figure 31 Adapted summary of Urban Environmental factors and potential areas

of action 40

Figure 32 Adapted version of Alexandra Indicators: table 45

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ACKNOWLEDGEMENTS ??Durban City Health Department for the Ekhupheleni Clinic Data ??Goodman Mgenge, Environmental Health Officer Durban City Health ??Ashwin Muratori, Environmental Health Officer Durban City Health ??Cathrine Oeloefse, School of Life and Environmental Sciences, University of

Natal, Durban ??Mark Kaplan, Cato Manor Development Association ??Angela Mathee, Brendon Barnes, Thea de Wet, MRC ??Bronwyn Curtis, MRC Health GIS Centre ??Robin Hamilton

All photographs, other than those that for which a source is indicated, were taken by Liz Thomas, with the kind assistance of Goodman Mgenge.

CHAPTER 1 INTRODUCTION 1.1. Background to the study This study was commissioned by the CSIR as part of the Lead Programme in Technologies for Enhanced Environmental Management which has as its aim “to develop a tool or tool box to identify technologies and actions for satisfying community needs and environmental quality in a cost-effective manner through collaborative research with local and international players.” 1 This is one of several commissioned studies which were required to provide background to the spatial area of Cato Manor and to the conceptual issues underpinning the initiative. The aim of this report is to provide an overview of the Environment and Health conditions of Cato Manor. The study is informed by the framework in the Alexandra State of Environment and Health Report by A. Mathee, B. Barnes and T. de Wet. (2000) and also comments on the framework in the abovementioned document. 1.2. Methodology Although Cato Manor is the location of considerable public investment though the work of the Cato Manor Development Association (CMDA), surprisingly little information is available on access to basic services across Cato Manor, although detailed information of specific upgrading initiatives/ projects could be obtained. For the purpose of this study a range of sources were used. These included: ?? 1996 Census data ?? articles in the press ?? review of published and unpublished material, including theses ?? the Cato Manor Development Project Status Report 2000 ?? discussions with key actors ?? Durban Municipality Environmental Health Officers, meetings, reports and a site visit ?? research reports on housing and environmental health which included a review of a

number of settlements, two of which were located in Cato Manor. The anticipated depth and range of information desirable for this report was not available. As a result, the actual data (based on the 1996 Census) is dated but is supplemented by insights and recent “topic-specific” research. This report comprises of the following components: a brief overview of the context (historical development of Cato Manor and description of the site), a profile of the environmental health conditions in the area, an overview of the health status of the population, the identification of key exposures and risks, conclusions and recommendations.

1 CSIR Lead Programme in Technologies for Enhanced Environmental Management Project Focus Document 31 March 2000

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1.3. Overview of Cato Manor

Cato Manor is an area of approximately 2 000 ha, the focus of intense urban development, and is located to the west of the Durban City centre. See Figure 1 (left), for an aerial view of Cato Manor seen in its metropolitan context with the port in the foreground and the Drakensberg in the distance. The site is very well located in relation to the city centre, employment opportunities and transportation routes.

Figure 1. Aerial view of Durban, highlighting Cato Manor (Source: http://www.cmda.org.za)

1.4. Historical development The area was named “Cato Manor” in the late 1800s after the first Mayor of Durban, George Cato, and was originally used as extensive farmland. Later, it was subdivided and used as Indian market gardens in the early 1900s. In time, the area developed into an extensive shack settlement with an estimated population of 17 000 in 1943 and expanding to between 45 000 and 50 000 people in 6 000 shacks in 1950.2 Seen as “illegal”, the residents had limited access to basic services, as shown in an early photograph (Figure 2). In many ways the poor environmental conditions experienced by the residents in the 1950s are very similar to the conditions of some of the current residents, although the current prospects for improvement are exciting.

Figure 2. A Cato Manor shack area prior to the establishment of the controlled emergency camp –circa 1955 (Source http://www.cmda.org.za/hisory.htm) The redevelopment of the site has a very strong historical significance, since it lay largely vacant for several decades as a result of forced removals by the apartheid government in the late 1950s and 1960s.

2 http://www.cmda.org.za/hisory.htm

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1.5. Current developments

Cato Manor is made up of several mini suburbs or “precincts”. The history, development and redevelopment of the various precinct areas differ, which results in a range of differing conditions and therefore implications for the findings of this report. One of the key differences relates to the income of the residents and therefore the levels of services in the different areas. Bonela, for example, is an area developed by the then “House of Delegates” which was responsible for Indian development and is largely developed with formal housing. In contrast, many of the other areas of Cato Manor are only now under development or the site of proposed development. A schematic map of the precincts of Cato Manor follows. 3 See Figure 3.

Figure 3 Precincts of the redeveloped Cato Manor (Source: http://www.cmda.org.za) The Cato Manor Development Association (CMDA) was formed in 1993 following the agreement of all key stakeholders that the area should be developed and the prime location and potential maximized. The CMDA has been actively involved in the management of the planning, upgrading, servicing and developing of the site as a mixed- use area since

1993. The Cato Manor Development Project’s Status Report (2000) documents progress comprehensively. 4 In terms of the report,

“The key strategic objectives of the Project are to create an efficient and productive "city within a city", targeting principally the poor and marginalised residents of Durban; to provide housing and security of tenure; to reduce existing infrastructure and service disparities; and to establish safe and secure living and working environments with ample economic opportunities.” “These objectives are being achieved through the delivery of an integrated development project whose key foci are the delivery of housing; social, educational and recreational infrastructure; land reform; local economic

3 An annotated map with a brief outline of the development status of the precincts can be found at

http://www.cmda.org.za/locationmap.htm 4 CMDA Status Report 2000 http://www.cmda.org.za/introduction.htm

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development and human skills development. Consisting of 900ha of developable land, the Project targets a yield of 25 000 housing units (accommodating 150 000 people) and the creation of 25 000 permanent jobs.” 5

Progress to date is extensive and ranges widely in form. Included is housing (sites serviced and houses built), the provision of bulk infrastructure (including transportation), the construction and establishment of social, educational and recreational facilities, economic and community development, to list only the main categories. 1.6. Housing The CMDA’s activities target a mix of income groups but with a strong focus on the poor. In terms of the proposals, half of the units are for households with a monthly household income below R1 500 pm, with a third (35%) for households with a monthly income between R1 500 pm and R3 500 pm, and a small percent (15%) for households with a monthly income above R3 500pm. As at June 2000, the housing initiative of the CMDA has resulted in 2 833 units built and 4 351 sites serviced. Progress with housing to date (7 184) amounts to nearly a third (30%) of the proposed 25 000 units. There are five main informal settlement areas falling into three precincts. They are Cato Crest Informal Settlement forming the Cato Crest precinct; Old Dunbar, New Dunbar and Ensimbini/Ematendeni in Wiggins precinct and Jamaica in Chesterville Extention precinct. The informal settlements in Cato Manor are estimated to house 7 500 families and the upgrading of these areas are the focus of the CMDA, which has secured funding for the upgrading of most these areas. Ultimately, the delivery of housing will involve a variety of housing types but current commitments indicate that the main type is for “single and double storey units on individual plots (85%) with very small areas allocated for attached and semi-detached single storey units (5%) or for low rise two-to-four storey apartments (10%).”6 1.7. Other developments “Izwe” newspaper, funded by the European Union and produced by CMDA, is a publication, which will be used increasingly to communicate with residents. In addition, there is a wide range of other development activities, not detailed here. 1.8. Future challenges Although several community facilities have been constructed, there would appear to be a substantial shortfall compared to the projected development yields.7 The CEO of the Cato

5 CMDA Status Report 2000 http://www.cmda.org.za/introduction.htm 6 http://www.cmda.org.za/housing.htm 7 http://www.cmda.org.za/keydimensions.htm

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Manor Development Project, Clive Forster, concludes the Cato Manor Development Project Status Report (2000) with a number of challenges facing the Project in order to consolidate its progress and ensure sustainability. These are listed and summarized for this report as: Urban management: “Substantial improvements in the urban management of the areas created through the project. This need spans a wide field, including: maintenance and operation of engineering infrastructure (roads, electricity, water) and public facilities and spaces; the guidance and regulation of private building practices; public transport management; and revenue collection; Higher levels of community safety: Despite substantial progress in this area, crime continues to impact detrimentally on the psychological, social and material well-being of the citizens of Cato Manor and impedes the private investment initiatives necessary to build the local economy; Private investment: Private sector and individual investment rates will need to increase dramatically in order to drive the economic and physical development processes forward; and Sustainable local development institutions: ?? Since 1994 the CMDA has been the main locus of development initiatives in Cato Manor.

The sustained development of Cato Manor will, however, require that development initiatives are increasingly undertaken by institutions with long-term horizons.”8

1.9. Key Issues 1. Cato Manor is an area rich in history, which is in a stage of massive urban development

largely for the lower-income groups, with extensive capital injection taking place. 2. CMDA as a development institution has taken a comprehensive and integrated approach

and is actively pursuing the realisation of its goals. 3. The current stage of development is an ideal window of opportunity to be able to

establish partnerships with key community, development and social agencies to be able to identify appropriate technologies for the further development of Cato Manor.

4. The existing community structures, linkages and newspaper could provide a useful mechanism for information and idea exchange.

5. The historical use of the land suggests that the land is suitable in parts for small-scale agricultural activity.

8 Cato Manor Development Project (CMDP) Status Report 2000 Conclusions

http://www.cmda.org.za/conclusion.htm

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CHAPTER 2: SOCIO DEMOGRAPHIC PROFILE

2.1. Introduction The population of Cato Manor is growing, due to the increase in land made available for urban settlement. The population in the 1996 Census was 84 882, made up of 14 008 households.9 The population density in 1996 is depicted in Figure 4 and shows higher densities in Cato Crest, Military and Wiggins - up to 463 people per hectare. The data is drawn from the 1996 Census. In view of the fast pace of development, the population profile is likely to have changed in the 4 years since the Census was undertaken. The planned population is expected to be between 150 00010 and 170 33111 suggesting that the current population of Cato Manor is expected to double.

2.2. Population profile The Cato Manor population is heterogeneous, with a small part comprising formal housing of middle income families and the majority comprising informal, housing mainly lower income families. The residents who have settled in Cato Manor have come from a broad range of areas within and outside of Durban, often having been born in rural areas12.

2.3. Age and sex profile According to the Census statistics, 51% of the population was female. The age and sex profile of the whole of Cato Crest shows a profile typical of an informal community with the population concentrated in the younger potentially economically active age groups (see Figure 5). The profile of the male population of Cato Manor in the age group 21-35 is much higher than the South African profile. Within the Cato Manor area, Cato Crest has an even higher percentage of young (21-35) potentially economically active males. The male profile comparisons are depicted in Figure 6. In 1996 there was a low proportion of the population that was school-going, most likely due to the lack of educational facilities in the area at the time.13 In addition, there was an absence of older people (over 50 years of age), including those who would largely be no longer economically active (over 65 years).

2.4. Educational profile The education profile of the Cato Manor informal settlements is close to what would be expected in an area which is largely informally settled. Of the population of Cato Manor over 20 years of age, 10% had not been to school, with 26% having only completed primary

9 1996 Census Data 10 CMDA Status 2000 http://www.cmda.org.za/introduction.htm 11 CMDA Table Population Figures for Cato Manor, which projects the future population of

the CMDA area to be 142 990 and the precincts of Bonela and Chesterville, outside of the CMDA direct jurisdiction, to be 27 341.

12 Hindson D., Pupuma F., 1996 p21. 13 Confirmed in article “Cato Manor on the fast track” Mail and Guardian August 28, 1998.

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Figure 4 Population density

0 0.5 1

kilometers

ChestervilleChestervilleChestervilleChestervilleChestervilleChestervilleChestervilleChestervilleChesterville

West RidgeWest RidgeWest RidgeWest RidgeWest RidgeWest RidgeWest RidgeWest RidgeWest Ridge

SparksSparksSparksSparksSparksSparksSparksSparksSparks

WigginsWigginsWigginsWigginsWigginsWigginsWigginsWigginsWiggins

UmkumbaanUmkumbaanUmkumbaanUmkumbaanUmkumbaanUmkumbaanUmkumbaanUmkumbaanUmkumbaan

Chesterville ExtChesterville ExtChesterville ExtChesterville ExtChesterville ExtChesterville ExtChesterville ExtChesterville ExtChesterville Ext

Cato CrestCato CrestCato CrestCato CrestCato CrestCato CrestCato CrestCato CrestCato Crest

Old DunbarOld DunbarOld DunbarOld DunbarOld DunbarOld DunbarOld DunbarOld DunbarOld Dunbar

MilitaryMilitaryMilitaryMilitaryMilitaryMilitaryMilitaryMilitaryMilitary

Waterval ParkWaterval ParkWaterval ParkWaterval ParkWaterval ParkWaterval ParkWaterval ParkWaterval ParkWaterval Park

BonelaBonelaBonelaBonelaBonelaBonelaBonelaBonelaBonela

WestvilleWestvilleWestvilleWestvilleWestvilleWestvilleWestvilleWestvilleWestville

UniversityUniversityUniversityUniversityUniversityUniversityUniversityUniversityUniversity

SherwoodSherwoodSherwoodSherwoodSherwoodSherwoodSherwoodSherwoodSherwood

HillaryHillaryHillaryHillaryHillaryHillaryHillaryHillaryHillaryUmbiloUmbiloUmbiloUmbiloUmbiloUmbiloUmbiloUmbiloUmbilo

BellairBellairBellairBellairBellairBellairBellairBellairBellair

1996 Population Density(per sq km)

18,500 to 46,300 (9)12,900 to 18,500 (11)

6,100 to 12,900 (9)2,800 to 6,100 (9)

0 to 2,800 (8)

Cato Manor: Population Density per Enumerator Area (1996)

Enumerator Areas (EAs)

EAs with no population

Place Names

Produced by: Health GIS Centre, MRC, DurbanSource: 1996 Population Census, Statistics South Africa

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Figure 5: Cato Crest Age Sex Pyramid (Source Census 1996) Figure 6: Male age comparisons for Cato Manor, Cato Crest and South Africa. (Source Census 1996)

0 2 4 6 8 10 12 14 16 18

M0_5YRS

M6_10YRS

M11_15YRS

M16_20YRS

M21_25YRS

M26_30YRS

M31_35YRS

M36_40YRS

M41_45YRS

M46_50YRS

M51_55YRS

M56_60YRS

M61_65YRS

M66_70YRS

M70_YRS

Age

gro

ups

Percent

Cato Manor percent Cato Crest South Africa

7066-7061-6556-6051-5546-5041-4536-4031-3526-3021-2516-2011-15 6-10

0-5

05101520 0 5 10 15 20

% Male % Female

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school, and the majority of this group could be classified as functionally illiterate.14 Under 1/5 (19%) had completed matric, with most of these having only matric (and no other post school qualification) and 4% with some post school qualification.15 This shows a shift in the educational levels from studies in the early 1990s, in which less than 10% had matric and nearly 50% had Std 5 or less.16

2.5. Employment profile The employment profile of the potentially economically active age group in Cato Manor (shown in Figure 7) reflects 45% employed, 26% unemployed and looking for work, and 29% not looking for work. Over half (55%) of the population would not be employed. Spatially, the greatest concentration of unemployed people is in the informal settlements (see Figure 8), Cato Crest, Old Dunbar and Military. In Cato Crest, a separate study has shown job creation as a top priority (mentioned by 96% of the sample) and suggested that 73% of residents in informal settlements were unemployed.17 Figure 7: Employment-related activity of the potentially economically active population of Cato Manor

(Source: Census 1996) 1n 1994 Xaba and Makhathini found that the occupational profiles of the Cato Manor shack areas and residents of the township of Chesterville were similar, with high proportions of wage earners in labouring (unskilled) jobs, domestic service in the informal sector and a small number of semi-professional, clerical and sales employees18. In view of the educational profile of the population, it is likely that a large percentage of those who are economically active work in the informal sector.

14 Functionally literate is taken to be a person who has completed Grade 6. Those who had

completed primary school would have completed Grade 7. 15 1996 Census data. 16 Reported on in Hindson D., Pupuma., 1996, p24. 17 Mugonda M 2000. p70 and p104 respectively. 18 Xaba and Makhathini 1994 reported in Hindson D., Pupuma F.,1996, p24.

45%

26%

29%

Employed

Unemployed

Not working

10

Figure 8 Unemployment

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National trends indicate that informal employment is growing (currently at 26%) and this trend is positive in the light of the absence of formal jobs.19 2.6. Key findings

1. The population profile of the area is typical of an informal area, with the highest concentration of the population being in the potentially economically active age group.

2. The very low percentage of children in 1996 is likely to have adjusted by 2000 to a more normal distribution with the building of schools in the area.

3. The low education levels are likely to result in relatively high levels of unemployment and employment in the low-income component of the informal sector.

4. Job creation is a priority. 5. The higher proportion of young people and (women in particular) makes the

population more likely to be at risk of being exposed to the HIV.

19 Baskin J 2000. The facts behind the figures, Mail and Guardian 27 November 2000.

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CHAPTER 3: LIVING ENVIRONMENT “In poor cities, and especially in poor neighbourhoods, environmental problems tend to stay close to home.” Gordon McGranahan 3.1. Introduction The characteristics and quality of the living environment are a critically important factor in determining the quality of life and health of households. In terms of the South African Constitution, “Everyone has the right to have access to adequate housing.”20 Interpreted in the Housing Act21, this refers to access to: ?? permanent residential structures with secure tenure, ensuring internal and external

privacy and providing adequate protection against the elements; ?? potable water, adequate sanitary facilities and domestic energy supply” being made

available on a progressive basis”.22 Studies of various other lower-income urban communities have highlighted a number of problems. In Port Elizabeth, the exposure of the lower wealth group to risks in their homes was a result of a range of factors, including building methods, materials and the siting of informal housing in poor locations. Problems experienced included damp, thermal inefficiency and overcrowding. Other problems related to poor ventilation rates in informal houses and the risks associated with paraffin (kerosene).23 In Alexandra, a number of environmental factors were highlighted as being associated with heath and were used to inform the development of environmental health indicators. Low-income communities are most susceptible to a range of health risks associated with their living environments. Most of the Cato Manor residents, particularly those in informal settlements, are living in risky environments. The aim of this section is to provide an overview of the living conditions in Cato Manor so as to establish the extent and nature of exposure to environmental health risks necessary to identify opportunities for technological development. 3.2. Cato Manor living environment The population of Cato Manor resides in a number of precincts. The largest share of the population resided in Cato Crest at the time of the census in 1996 (44%). The proportion of households in each of the suburbs at the time of the Census (1996) is depicted in Figure 9. In 1996 the population lived largely in informal structures (62%), with only 18% living in formal housing. (See Figure 10.) Since 1996 there has been substantial private and public

20 Article 26 of the Bill of Rights in the Constitution. 21 Housing Act 107 of 1997 22 BESG 1999 Towards the Right to Adequate Housing, p 4. 23 Thomas EP et al 1999

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Figure 9: Distribution of households by spatial area in Cato Manor (Source Census 1996)

Figure 10: House types in Cato Manor (Source Census 1996)

2 2

62%

18%11

5

House Types

Informal

Formal house

Backyard(Informal)Traditional

Distribution of households in Cato Manor

16%

44%1%

10%

3%

15%

0%4%7% Bonela

Cato Crest

Chesterville Extn

Military

Nsimbini

Old Dunbar

Umkumbaan

Waterval Park

Wiggins

14

investment in the area and currently (2000) it is estimated that 7 50024 people live in informal structures and an increasing share in formal housing. Old Dunbar and Wiggins are two settlements in Cato Manor which were recently included in a series of studies used to inform a report called “Towards the Right to Adequate Housing.”25 The two studies, which are of relevance to this report, are on environmental health26 and housing.27 Residents of Old Dunbar, an informal settlement and Wiggins, an area of new housing, were interviewed about a range of issues. Some of the results of the studies (secondary data) are presented below. It would appear that further analysis of some of the primary environmental health data could be informative although it has not as yet been possible to access the primary data. 3.3. Access to basic services Access to basic services improved as a result of the massive investment and upgrading programme under the auspices of the CMDA. In the mid 1990s, there was grave concern about the environmental problems in Cato Manor and in “all settlements, there was an acute sensitivity to the linkage between environmental conditions and health”. All three informal settlements were seen to be endangered by extremely unhealthy living conditions brought about by poverty, the lack of basic sanitation and solid waste removal services and the lack of health facilities such as clinics28. Access to piped water; waterborne sewerage and waste removal services in 1996 were seen as of paramount importance.29 The position in 1996 per suburb, highlights the very different levels of access to basic services and therefore environmental quality between the areas (see Figure 11).

24 CMDA Stats Report indicates 7 500 although the Durban City Health, Third Quarter

Environmental Health Report on Informal settlements (2000) suggests that there are 7 888 informal structures in Cato Manor. 25 Built Environment Support Group 1999 Towards the Right to Adequate Housing, European

Union Foundation for Human Rights in South Africa, BESG, Pietermarizburg and Durban 26 Maharaj R., (undated) Evaluation of Low Cost Formal Settlements and Informal

Settlements from an Environmental Health Perspective, Prepared by the Industrial Health Unit, University of Natal, Medical School, for the Built Environment Support Group(unpublished)

27 Oelofse C., Environmental Considerations in Low Cost Housing Projects, report for BESG, December 1999.

28 Hindson D., and Pupuma F., 1996 p33. 29 Hindson D., and Pupuma F., 1996 pp38, 40.

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Figure 11. Access to basic services in suburbs in Cato Manor in 1996 (Sources: 1996 Census* and Durban City Health Environmental Health Report

September 2000#)

Use of public water supplies

% * 1996

Use of non-flush toilets

% * 1996

Total number of households

*1996

Total number of shacks

September 2000#

Bonela 0 0 1234 Cato Crest 48 99 6659 5045 Chesterville Ext 0 0 82 335 Military 94 97 1521 Nsimbini 98 100 489

331?

Old Dunbar 92 97 2332 2163? Umkumbaan 0 0 0 Waterval Park 0 0 616 Wiggins 1 1 1075

? Ensimbini Booth Road ? ? Old and New Dunbar The overall quality of the environment has improved substantially since 1996. While many areas have been serviced with incremental improvements, the largest informal area in Cato Manor, Cato Crest, is yet to be formally upgraded. 3.4. Water Overall, 50% of the population in 1996 relied on public water sources while the balance had a water supply in their homes. Access to water shows very big differences between the precincts. Half of the Cato Crest population relied on public water supplies while in Military, Nsimbini and Old Dunbar in 1996, over 90% of households used public supplies of water (see Figure 12). The burden of fetching water is most often borne by women. In Port Elizabeth, females carried 80% of the water from communal taps and children were responsible for 13% of all water carried. Female children, like adult women, were five times more likely to be collecting water than their male counterparts.30 Although many women were seen carrying water in Cato Manor, interestingly men were seen congregated around the standpipe! (see Figure 13).

30 Thomas, E. P., Seager, J.S. et al., 1999. Household Environment and Health in Port

Elizabeth, South Africa. Urban Environment Series No. 6. Stockholm Environment Institute (Stockholm). p61

16

Figure 12 Access to water

17

Insert Figures 13 and 14 as page 17

18

Water provision in Cato Crest has been upgraded with the provision of a 200l tank to each household, which is filled daily through a distribution system (see Figure 14). The implementation of this system has reduced the time that households spend in water-related tasks, as they no longer need to carry water, wait in queues, etc. There are, however, certain problems that are associated with the tanks. Although the location of the tanks on the individual stands will reduce the health risks associated with communal water sources, there is concern that the siting of the tank may not be optimal for health. In particular, the height of the plinth on which the tank is based as well as the “around tap conditions” may not maximize the health benefits of the investment. Several of the tanks, on observation, were too low and were surrounded by dirty environments and animals, which are possible causes of contamination of the tap and therefore the water. Problems from the “two settlement” survey highlight complaints regarding water quality and maintenance. People complained about dirty water entering the tanks (27% of the sampled households in Wiggins) and the presence of small red worms in the tanks (3% of the households in Wiggins).31 In addition, there were complaints about leaking water tanks (9%), and the tank cover being lost (16%) or insecure.32 The Environmental Health Officer reported his ongoing involvement in health education initiatives and chlorination of tanks, as well as working closely with clinic staff when people with water-linked health problems presented at the clinic. 3.5. Sanitation Like access to water, there are wide variations in the Cato Manor area in access to flush sanitation. The census data reflects that 45% of the households did not have the use of a flush toilet (see Figure 15). Current Durban City Health estimates are that there are only 403 households (5%) out of a total of 7 888 shacks which rely on pit toilets.33 The geotechnical conditions dictate that waterborne systems are necessary. Although there have been ongoing initiatives to improve the supply of sanitation services, several communities are still reliant on on-site disposal (see Figure 16). While areas will be upgraded in time, there is a health risk associated with on site disposal in high density settlements, especially where the soil conditions are not appropriate. Outbreaks of shigella and cholera have occurred in the past two years.34

31 Mr Goodman Mgenge (EHO) reported on the problem of the small red worms. Samples

were taken but the water was not found by the Metro Water Laboratory to be contaminated.

32 Maharaj R., (undated) p24. 33 Durban City Health, Third Quarter Environmental Health Report (2000) on Informal

settlements and Development Projects, September 2000 34 Personal communicationm. Mr Goodman Mgenge, EHO.

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Figure 15 Access to sanitation (1996)

Figure 15 Access to sanitation

20

Figure 16. Pit toilets are problematic and can impact on health

3.6. Refuse removal and waste services

Refuse removal services are provided by the Durban Department of Water and Waste with the recent introduction of free refuse bags (see Figure 17) distributed by the Council in the informal settlement areas (see Figure 18). Some residents reported that they recycled waste, either reusing it or selling it.35 In Cato Crest, most of the residents have assessed the current system as poor (72%)36, with more than half (57%)

viewing the current Durban Solid Waste (DSW) system as inadequate.37 The majority (80%) ranked waste as an issue of concern.38 While skips have been provided, the community is not satisfied, in part because often the waste is not put in the skip and the location/ design of them also makes it hard for the elderly and children to use the skips effectively. Figure 17. Refuse bags in Cato Crest waiting for collection

The area has been subject to widespread dumping in the past and this is clearly evident and results in a poor quality environment. Illegal dumping has been identified as posing a number of threats from bacterial diseases. Dumped goods causing a problem include putrefying meat, poisonous substances, paint, thinners and insecticides.39 Residents of

Figure 18 Access to refuse services

35 Mugonda M., 2000 p74 reporting on reuse and sale of plastic (17%, 7%), glass (28%, 59%),

tins (9%, 17%) and newspaper (50%, 8%) respectively in Cato Crest. 36 Mugonda M., 2000 p4. 37 Mugonda M., 2000 p86. 38 Ibid. p 70. 39 Cato Manor Draft Structure Plan 1997, reported on in Mugonda M., 2000 p71.

21

22

Cato Crest said that illegal dumping occurred for a range of reasons, such as there being no suitable places for waste disposal, irregular waste collection, lack of bins, dogs scavenging, etc.40

Nearly all the residents interviewed saw unmanaged waste as causing the spread of disease (89%).41 Health concerns raised included problems with children playing in and around dumps, and rats and other rodents which carry diseases into shacks and thus spread diseases. Cholera was also blamed on poor waste management.42 The waste was found to also accumulate in water courses, a popular area for children to play, in while also contributing to pollution of the rivers downstream (see Figure 19).

Figure 19. Pollution in the Umkumbaan River adjacent to Bellair Road When asked about possible ways of addressing the waste problem, the Cato Crest residents interviewed suggested that voluntary community policing (20%), the introduction of penalties and prosecution (28%), and

awareness campaigns at a community level (11%) could be used to make a difference.43 A number of those interviewed were in support of a one-man contractor system as well as other mechanisms, including making the broader community responsible for their environment.

The study concludes that ”…. [T]he current waste management service is inadequate and this is leading to the degradation of the environment and it also subjects residents to a serious danger of diseases.”44

3.7. Access to electricity

Several areas in Cato Manor are not as yet electrified, as depicted in Figure 20. Where households have access to electricity, it is almost always the preferred source of energy for lighting. Paraffin (kerosene) is used as the source of fuel for cooking by hose without electricity (in many of the informal areas) and some poorer households in

Figure 20 Access to electricity

40 Mugonda M., 2000 p77. 41 Ibid. p86. 42 Ibid. p80. 43 Ibid. p82. 44 Ibid. p104.

23

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electrified areas.45 In Cato Crest, 86% of households were using paraffin while the balance used paraffin and gas or paraffin and wood.46 Paraffin was also used as a heating fuel in 15%-20% of households.47

While the health consequences of paraffin usage are not yet known, a preliminary scoping study undertaken in Port Elizabeth has identified paraffin as a potential source of exposure to a range of hazards, recognizing that the type of appliance, age and handling plays a role in the makeup of emissions. Carcinogenic components of the emissions are expected to mainly be non-methane hydrocarbons and PAHs. The primary health concern associated with the emissions is likely to be acute and chronic respiratory irritation, especially in children and asthmatics. The study also noted that when windows and doors are closed (for example during cold or windy weather) the exposure to emissions from the burning of paraffin expected to increase.48

A recent air quality study has been undertaken of households using paraffin for cooking in Cato Crest. The aim was to explore the health risks associated with its use. The results of the air quality monitoring have not yet been analyzed but when complete, the findings will be able to give an indication of the risks associated with paraffin usage.49

Given the concern raised about ventilation, the Cato Crest study (referred to above) found that in the evenings, most households did not open their windows while cooking (over 90% did not in winter or summer). During the day, while most did open their windows while cooking, between 28% and 50% did not (summer and winter respectively). This finding was confirmed in the work of Oelofse (1999) who found that “Residents in Wiggens said that they had to sleep with the doors and windows closed for security reasons and this made the houses very hot at night. All residents stated security was a key issue to quality of life and something they desired strongly”. The practice of keeping windows and doors closed for security and privacy reasons may well have health consequences as far as ventilation is concerned.

45 55% of residents in Wiggins Fast Tack, BESG Study quoted in Maharaj, p25. 46 Preliminary results of the CSIR, 2000. Indoor Air Quality Monitoring in Cato Crest, Cato

Manor: Raw Data. Lead Programme in Technologies for Enhanced Environmental Management, Report no. P5-5, Durban.

47 15% in formal housing and 20% in informal housing, BESG study reported on in Maharaj, pp 25,26.

48 John, J., Oosthuizen, T., Schwab, M., 1999 Indoor Air Quality and Paraffin Use in Port Elizabeth, PE Household Environment and Health Series, Report 2.

49 CSIR, 2000. Indoor Air Quality Monitoring in Cato Crest, Cato Manor: Raw data. Lead Programme in Technologies for Enhanced Environmental Management, Report no. P5-5, Durban.

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3.8. Access to telephones

From the census most households in Cato Manor in 1996, had access to a phone” nearby” (86%) or in their homes (10%)50. In a study in Cato Crest specifically, improved access to telephones was a concern voiced by two out of every three people (65%), interviewed in the sample.51 Access to telephones is particularly important to enable emergency services to be called quickly, when needed because of fire, etc. 3.9. Housing The provision of housing is taking place under the auspices of the CMDA, as reported above. While it is accepted that housing delivery is a process, user satisfaction should be regarded as an important consideration in housing delivery. Access to a housing subsidy, available to low-income households, does not necessarily result in recipient satisfaction. This section draws on a review of a sample of formal and informal housing in Cato Manor and highlights a number of housing-related problems linked to health, which are experienced by the residents. Formal housing A study of housing in Wiggens highlighted a number of problems, some of which are determined by financial limitations in low-cost housing delivery while others are related to design, technology construction and maintenance. Overall only 62% of the residents were satisfied with their houses.52 One of the key problems was that of size. The components were the size of the structure (a cost factor) (a concern for 87%53), size of site and lack of land for expansion (49%).54 The hilly topography in most of Cato Manor results in steep slopes (seen as a problem by 45%) which limits the possibility of expanding houses, as well as resulting in a range of problems such as treatment of embankments, storm water runoff (a problem for 87% of the households), etc. The structure in Figure 21 highlights a problem experienced by many living in housing recently constructed using the housing subsidy - that of size. This owner is extending the house considerably, although due to financial and space constraints, many of those wanting to expand their structure are heavily constrained.

50 34% of all South Africans and 20% of African households had “universal service” (fixed

or cellular phones) in 1999, October Household Survey 1999. Data collated by Peter Benjamin, personal communication, December 2000.

51 CSIR, 2000. Indoor Air Quality Monitoring in Cato Crest, Cato Manor: Raw Data. Lead Programme in Technologies for Enhanced Environmental Management, Report no. P5-5, Durban. p70.

52 Oelofse C Environmental Considerations in Low Cost Housing projects, report for BESG,

December 1999. p7 53 Ibid. p26. 54 Ibid. p9.

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The structure in Figure 21 shows one of many houses being extended

The second key problem is that of construction and design. These pictures show the problems that new residents are having with their formal housing, namely problems with poor roof/ wall sealing mechanisms (Fig. 22, left), a lack of ventilation in the design and construction resulting in the subsequent insertion of air bricks in both houses, Fig 23, below.

One of the results of a lack of ventilation, is the buildup of damp conditions inside of houses. Not surprisingly, the residents have also complained about dampness in their dwellings, which can be seen in Figures 24 and 25.

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Damp walls have been found in recently constructed formal housing and attempts are being made by home owners in formal and informal housing to limit the exposure of the structure to damage from rain water which has undermined the structure and caused damp. The dampness has implications for both short and long term respiratory health.

Figure 24 A damp south-facing wall in a contractor built house

Figure 25 An informal structure surrounded by an informal earth drainage area, dug to protect the structure from being damaged by runoff and standing water

The internal design and construction of the formal houses was also a cause for concern. The houses were reported to be too hot in summer. The orientation of the houses, as well as the design and positioning of windows and doors, are determining factors.55 Concern was also raised about the poor design of bathrooms (being too small), the location of internal taps and the close proximity of internal taps to electricity boards.56 The design problem in the bathrooms could be addressed through design revisions with resultant cost implications.

55 Oelofse C., 1999, p 11. 56 Ibid p21.

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The positioning of taps and electricity boards in close proximity to one another is illegal.57 This problem should be addressed in two ways, retrospectively through the appropriate repositioning of the electricity boards in the affected houses and proactively through design and construction meeting safety standards. The existence of the taps and electricity boards in close proximity to one another raises questions about the extent to which the National Building Regulations have been complied with, the assessment criteria used for the approval of house designs, as well as the approval of completed structures by the Council. The design of the grey water system would also appear to be problematic as residents are required to work out a system for themselves, usually resulting in grey water being released in to the yard. Provision is not made to allow for grey water to be discarded into the sewer system, probably as a way to limit the demand on the bulk system.58 “The disposal of water is an ongoing problem for residents and all those interviewed complained of having to deal with this issue.”59 The residents were dissatisfied with both the water and sanitation systems, many of the problems arising due to a lack of maintenance and the poor functioning of the systems.60 Some of the problems can be addressed through health and maintenance education but there is also a need for the public maintenance of services.61 3.10. Emergency services Access to emergency services is often important for communities living in informal areas due to the high population density, informal building methods and materials, risky locations and the use of certain fuels. Fires have occurred twice in the past two years. The cause was reported to be a candle, which fell over resulting in runaway fires that destroyed forty shacks, in both instances leaving 41 families homeless.62 While emergency firefighting services are available in the Durban area, due to the close proximity of shacks to one another, the service is often unable to respond quickly enough before substantial damage has occurred because problems of accessibility. Community fire awareness and response capacity building suggested as ways in which the occurrence and impact of fires can be reduced. Some of the settlements in Cato Manor are located within flood plain areas which means that they are very susceptible to flooding. In the past two years, flooding has occurred once in November 1999. One hundred shacks were flooded and 13 collapsed.

57 SABS 1042. 58 Ibid p19. 59 Ibid. p19. 60 Ibid. p21. 61 Ibid p 22. 62 Personal communication Mr G Mgenge, EHO.

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In cases of emergency, the Disaster Management Department is available to respond and along with the Red Cross and Army, provide humanitarian aid.63 3.11. Community facilities Although there were a limited number of facilities in the area before Cato Manor was reoccupied, such historic temples, a number of facilities have been built in the 1990s. These include Cato Crest multi purpose centre, Wiggins multi-purpose centre, Bellair centre, Bellair market, Umkumbane library and a number of primary and pre-schools. 3.12. Health services The current and planned facilities will be described. Current provision

In the early 1990s the Chesterville clinic was originally the only facility available for the residents of Cato Manor. The Durban City Health Department has provided a mobile clinic service located at the Westpark Tennis Stadium since 1993. One of the most recent facilities to be built in Cato Manor is the Ekhupheleni Clinic, which is centrally located on Bellair Road in Cato Manor. Serving almost the entire population, the facility has 16 procedure spaces and has been in operation since 1998 (see Figure 26).

Figure 26. Aerial photograph of the Ekhupheleni Clinic, Bellair Road. (Source CMDA)

63 Personal communication Mr G Mgenge, EHO, Durban City Health.

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Private health care services are available in Cato Manor in the form of general practitioner surgeries and a pharmacy, two of which are located in a new commercial centre, as shown in Figure 27. Figure 27 Private health services on Bellair Road

Primary health care and hospital services in the Durban area are considerably underprovided, with a deficit of 26 clinics and 15 community health centres.64 Planned facilities

The Greater Cato Manor Structure Plan (1995) provides for purpose-built clinics and a community health centre. A subsequent Health Plan has been prepared to facilitate the provision of health facilities as well as to ensure the health services and facilities provided to match the socio-economic profile of the projected groups and provide a safe and healthy living environment for residents. It is expected that 75% of the population of the Cato Manor is reliant on public health services.65

The facilities required for the future population of Cato Manor have been assessed. These are five clinics and one Community Health Centre. The Community Health Centre will be a higher order facility providing a multi-purpose comprehensive facility, including an obstetric unit for 12 beds, dentistry, physiotherapy, X-ray services and an extensive health education space. The current operational Bellair Road Clinic, Ekhupeleni, is considered to be one of the five clinics. The spatial location of the facilities has been decided upon.

Funding has been secured from the European Union for the construction of the Community Health Centre but the funding of the operational costs has not been secured. CMDA has been very actively involved in trying to get a range of actors

64 Durban Functional Region Draft Health Plan (May 1995), as quoted in CMDA Greater Cato

Manor Health Plan, January 1998. 65 CMDA Greater Cato Manor Health Plan, January 1998, p7.

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committed to operating from the proposed Community Health Centre. Funding from Durban City Health has not as yet been secured.

The new regional academic teaching hospital, located to the south west of Cato Manor, is nearing completion. It will have 800 beds, involves investment of R1 billion and will open its doors in 2001. 66 (see Figure 28.) This facility will not be for the residents of Cato Manor only, as it serves the entire metropolitan area.

Figure 28 Albert Luthuli Central Hospital, the metropolitan facility

The health profile of the population is outlined in the next chapter.

66 The British NHS Director praises Cato Manor, The Mercury, 6.10.1999

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CHAPTER 4: HEALTH PROFILE 4.1. Introduction The health profile of the community is best ascertained through the use of a variety of tools, such as a random survey of households asking questions about the health of the household, the use of two-week recall of health problems, health perceptions, clinic records, hospital records, etc. In this case, household level information is not available, so a range of other indicators is used to ascertain the health of the community. 4.2. Visits to the clinic Ekhuphileni Clinic was built during 1997/98 and records are available from March 1998. The data output available for the clinic reflects the broad data base facility at DCC and is still in a development phase, although the data collected is detailed.67 The Durban City Health Department is involved in managing a Health Information System for all its health facilities. The data collected at Ekhuphileni Clinic is collated and managed by the Durban City Health Department. Limited data is available but highlights some of the main health problems experienced by the residents using the clinic. The data reflects broad age categories, with the youngest being 0-14 years, rather than the more useful under 6 age group data, which would give an identification of the extent of (environmental) health risks to young children. After an overview of the clinic data, the position for the under 14s is presented. The clinic records show that 24 264 visits were made to the clinic between March 1998 and December 1999. Of these, 8 930 were first visits and 15 334 follow-ups. This amounts to 1 155 visits per month over the 21 months from its inception. 37% of all visits were new visits in the first 21 months. The percentage of new cases remained the same in 2000, with the percentage of new visits 36% and repeat visits making up 64% of the total of attendees. 4.3. Main reasons for visits to the clinic Drawing from the 2000 data for a period of 7 months for the clinic as a whole, the main services provided by the clinic for new episodes were for skin conditions, upper respiratory conditions, ear, nose and throat conditions, and unspecified reasons. (See Figure 29). These are depicted in Figure 29 which is a summary of the data for the period January to July 2000.

67 Mr Harold at DCC Health

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Figure 29. Main complaints by those attending the clinic during 2000 JANUARY –JULY 2000

Total number of new episodes

% of total problems

Rank

Anaemia 407 5.53 6 Asthma 58 0.79 Burns 18 0.24 Cardio-vascular 42 0.57 Central nervous system 72 0.98 Diabetes 26 0.35 Ear, nose, throat conditions 610 8.29 4 Eye 119 1.62 Gastro-enteritis 263 3.58 Gastro-intestinal 234 3.18 Gynaecological 442 6.01 5 Hypertension 125 1.70 Infectious diseases 7 0.10 Lower respiratory infection 254 3.45 Muscular 205 2.79 Nutritional 277 3.77 Other 866 11.77 3 Respiratory 288 3.92 Skin 1294 17.59 1 Surgical 87 1.18 TB 30 0.41 Upper respiratory 949 12.90 2 Urological 219 2.98 Worms 139 1.89 Sub-total 7 034 95.62 STDs 322 4.38 7 Total visits 7 356 100.00 Of note are the high incidence of certain problems, such as skin, upper respiratory infections, ear, nose and throat, gynaecological conditions and anaemia. STDs are also ranked among the top ten problems and should be seen as a possible proxy indicator of HIV/AIDS.

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Figure 30 below shows the shifts in the percentages of cases treated for a range of conditions. This shows that anaemia, CNS and gynaecological problems seem to have increased in number while ENT, gastro-intestinal, nutritional and respiratory problems seem to have decreased somewhat. The reasons for these trends are not known and would need to be followed up with a more detailed study. Figure 30. Change in share of cases over two time periods 1988-2000 2000

Share of cases 1998/1999

Share of cases Top 5 in share of

cases

Shift in direction

Anaemia 7.92 3.43 up Asthma 1.24 0.83 Burns 0.26 0.50 Cardio-vascular 0.43 0.20 Central nervous system 1.22 0.53 up Diabetes 0.56 0.16 Ear, nose, throat conditions

9.36 11.56 ? down

Eye 2.93 1.82 Gastro-enteritis 4.01 3.14 Gastro-intestinal 3.20 5.85 down Gynaecological 4.19 2.73 up Hypertension 2.61 1.61 Infectious diseases 0.10 0.27 Lower respiratory 4.05 3.96 Muscular 2.75 2.70 Nutritional 4.10 6.65 ? down Other 11.02 7.88 ? Respiratory conditions 4.92 6.01 down Skin 15.99 16.73 ? same Surgical 0.82 1.39 Tb 0.38 0.18 Upper respiratory 14.43 15.59 ? same Urological 2.13 2.23 Worms 2.62 4.04 down Sub total Total visits 100%

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The data is not available in suitable age categories to allow disaggregation of the number of under 5’s attending the clinic, nor the conditions that they present with. The data set available reflects broad age categories, with the youngest being 0-14 years, rather than the more useful under 6 age group data which would give an identification of the extent of (environmental) health risks to young children. Noting the above: Nearly one third (31%) of all visits to the clinic, were for children under 15 years of age. The main reasons given for visiting the clinic differ between the group under 15 and the group of those aged 15 and above.68 The top 6 reasons for under 15’s visiting the clinic were: ?? respiratory conditions 31% (upper respiratory 19%, respiratory 7% and lower

respiratory,5%), ?? skin (22%), ?? ear nose and throat (15%) ?? gastro enteritis/ gastro intestinal (10%),(6.29%, 3.38% respectively) ?? other (9%), and ?? worms (5%). Notably absent from the top 6 list for young people are burns (0.43%) and nutrition (1,97%) as reasons for visiting the health facility. Main reasons for visits to the clinic for adults: (those aged 15 and above): ?? skin (12%) ?? upper respiratory (11%) ?? STDs ( 11%) ?? other (11%), and ?? anaemia (10%) 4.4. Data constraints The Clinic data reported on above provides an indication of the typical health problems experienced by the residents. The data as presented merely points to certain problems. Over time the clinic data would be useful to be able to show trends. This is not possible due to the recent opening of the facility. Should a more specific health review be commissioned, other sources of data could also be used to provide a health profile of the residents. These would involve undertaking a household health and environment survey, which could be designed to provide a comprehensive baseline of both chronic and other conditions. This data set could be supplemented by other data sets that would not be comprehensive, but could give some indications of problems, such as the TB data from King Edward V Hospital, HIV/AIDS NGOs in the area, school health reviews etc. 4.5. Environmental health services The Cato Manor area is part of the North and South Central Local Councils, now subsumed under the Durban Unicity. Environmental health services are provided from the Old Fort

68 2000 data Jan – July Inclusive

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Place Offices of Durban City Health. The EHOs are involved with a range of activities in Cato Manor. This involves close liaison with the Clinic staff when problems arise. The EHOs are also involved in liaising between the community and other departments in Durban City Council for example Metro Water, Solid Waste, Emergency services etc. The EHOs are also called upon by the CMDA, NGOs and other groups, such as the CSIR in undertaking studies and projects. They have also recently been involved with the social workers in Durban City Health in the launching of a Health Forum in the area, during August 2000. The nationally accepted ideal is for a ratio of 1 EHO for 10 000 people69. Ultimately there should be approximately 15 EHOs working in Cato Manor with 10 at present assuming a population of 100 000 people. The Kwa Zulu Natal current ratio of EHOs to population is 1: 27 044, similar to the South African ratio of 1: 21 71970. Durban City Health currently provides one full time EHO and a share of another’s capacity. This is clearly inadequate for the size of the population and more importantly in relation to the prevailing environmental health challenges. 4.6. Concluding Comments The data shows that skin conditions, upper respiratory conditions, ear, nose and throat conditions are among the most often that are troubling the community who make use of the Durban City Health Clinic in Cato Manor. The environmental health services provided are inadequate for the size of the population and the nature of the living environment of the residents, where environmental health problems are most concentrated. This urgently needs to be addressed. The Community Health Forum, which has recently been set up will provide a potential avenue for close liaison between the health service providers (at the clinic, GPs etc) and the end users. The proposed Community Health Centre, discussed in Chapter 3 would enable a comprehensive range of services to be provided under one roof. The location of a health education centre, EHOs and NGOs providing health-related services at the health facility, as envisaged, will go a long way towards the provision of comprehensive primary health care for the residents of Cato Manor. The health services to the community needs to be urgently supported by the increase in the provision of environmental health services providing preventative health services.

CHAPTER 5: HEALTH EXPOSURES AND RESPONSES

69 Mathee A., Swanepoel, F., Swart, A., 1999 Environmental Health Services, Chapter 20 in South African Health Review, HST. http://www.hst.org.za/sahr/99/chap20.htm. 70 Ibid.

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5.1. Overview: Health and environment context and linkages There is an acknowledged complex synergism of physical, social, economic, political and cultural elements in the urban ecosystem (WHO, 1990). In a comprehensive review of urban environmental health studies, the authors conclude “…as a fundamental variable, poverty remains the significant predictor of urban morbidity and mortality” while “…addressing the intermediate variables of the urban physical environment, is a partial approach to improving urban quality of life.”71 There is a concern that the emphasis in the past on urban physical and socio-economic deprivation (poverty) and how this impacts on health results, in the focus on addressing these problems being placed on the household/ individuals rather than on the underlying structural causes of the deprivation, which result in ill-health.72 Taking the above into consideration and given the close correlation found between “poverty and a deficient home environment in cities, separating them as causal factors in disease is difficult”.73 Attempts have been made to map the environmental determinants of health problems. These differ in part by the starting point either the health outcome (disease) or environmental property. The complexity of factors is shown diagrammatically in Figure 31. This model focuses on the environmental conditions as the determinants.74 Post 1994 South Africa has a number of policies in place aimed at addressing the inequalities of the past. In addition to the right to vote, providing political empowerment, these include tackling economic poverty through job creation, meeting housing and other basic services needs as well the extension of the primary health care network. The health of the poor will to a large extent be determined by the success of these policies in addressing the structural poverty and resultant inequality of the past. This case study of Cato Manor focuses on the aspect of environmental health and reviews how current strategies are managing to meet the needs of the poor.

5.2. Cato Manor Overview: Health and environment linkages: The findings of review of the physical and social environment in Cato Manor provide a typical profile of poorer sections of a city. Even within the area under consideration wide variations in income, educational levels, and access to basic services have been shown. It is likely that the intra urban variations found in living conditions would translate into varying morbidity and mortality profiles within and between communities living in Cato Manor. However, the health data obtained for this study reflects only the health problems that people sought

71 Bradley D.J., Stephens, C., Harpham, T., and Caincross, S. 1992, A Review of Environmental Health Impacts in Developing Country Cities, Urban Management Program, The World Bank, Washington, p32. 72 Mitlin et al (1996) quoted in Harpham T., et al 2000 Urban Health Review, National Academy of Science, USA. 73 Op. Cit. p33. 74 Ibid p5-6.

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help for at the main primary health care public health facility in the area. The health data for an individual cannot be linked to their home environmental conditions. (The use and limitations of clinic-based data will be explored further in Chapter6.) It is difficult therefore to be able to link the health problems (presented at the clinic) with specific environmental factors, other than theoretically through known pathways established in disease-specific research. Physical environment: While many of the problems in the physical environment are addressed when an area is upgraded, there is also a concern that at times, the newly constructed houses fail to meet the resident’s expectations75 or generally acceptable building performance standards. The environmental health conditions presented in the previous sections highlight a range of risks that the residents of Cato Manor are exposed to. As Cato Manor is to be developed for lower income communities, in a context of constrained budgets for public investment, resources/ investments need to be used to maximize health benefits. From the study, it is clear that the range of exposure to environmental risks is not only limited to the communities living in informal settings in Cato Manor. Despite substantial public investments through the housing subsidy process, the residents in the formal housing areas are experiencing a number of problems related to their living environments. The key findings of the study are listed below. Who is exposed to risks? The population of the area of Cato Manor is not all exposed to environmental health risks to the same extent. Those living in the precincts with higher levels of unemployment (as an indicator of socio economic status in the absence of income data) are likely to be living in poorer quality housing. In the case of Cato Manor, the exposure to risk could be broadly linked to population density with those living in areas which have higher densities, (the informal settlements), being more exposed to poor quality living environments. People who spend long periods of time in the area, not going out of the area for work etc such as the unemployed, women, elderly and children are likely to be exposed to risks on a continuous basis. What are the risks and where are they concentrated? At home: People living in informal environments are exposed to more risks than those living in formal housing suburbs. The risks in the informal areas include: Water: Access to unreliable water sources, having to collect and carry water from public supplies, unsafe/ unhygienic storage of water at home.

75 Shoddy work angers housing scheme residents, Daily News, 19.07.2000

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Sanitation: Reliance on pit toilets by some, and the exposure of residents in the surrounding areas of contamination of water sources and the environment as a result of seepage especially after heavy rains. Housing (Informal): Lack of space, overcrowding, psycho-social impacts of living in overcrowded conditions due to a lack of privacy, children sleeping on the floors, lack of personal safety, lack of safety of possessions, lack of protection form the elements (wind, heat and rain), flooding of houses, exposure to damp, indoor air pollution, fire, exposure to vectors such as rats, for example. Outdoor environment: Refuse, poor quality roads, fast moving traffic, unsafe neighbourhoods due to crime and a lack of street lighting, ambient air pollution, close proximity of neighbours due to high density living, poor quality play spaces for children, etc. Housing (Formal) While the Housing subsidies are expected to result in improved quality housing and living environments, the study has shown that this is not necessarily the case. The review of Wiggens by BESG has highlighted that the delivery of top structures on serviced sites has not necessarily improved the living environment of the recipients. Problems that emerged relate to a range of concerns. The site: Lack of space for expansion, problems with house and site orientation, steepness of the slopes and need for ensuring slope stability with retaining walls/ structures, adequate channeling of run off water, poor township and road layout exacerbating runoff problems etc. The house: (design and construction) Size of the structure, design not accommodating expansion, exposure to the elements through poor design (orientation, runoff, location of windows and doors limiting cross-ventilation, lack of air bricks), poor bathroom design, location of taps, poor construction of roof/ wall interface and damp walls. Services: Water and sanitation is provided on site but problems have emerged as a result of poor construction methods/ installation, lack of maintenance, technical design solutions which may not be health-promoting such as inadequate provision being made for sullage. Despite the range of health risks associated with the physical environment outlined above, there are ways in which the risks of the environment can be mitigated. There are two key groups. The first are the end-users or residents in these areas who can be targeted through awareness to promote behaviour change. However, some of the concerns are structural which requires a greater awareness of health and development linkages by professionals involved in the built environment and urban management. Some of the health risks raised relate to a lack of knowledge and awareness by community members. These include health education on a range of issues at schools, health facilities and in the community so as to provide opportunities for the transfer of knowledge, increasing levels of awareness about the issue that can lead to behavior change.

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The exposure to environmental health problems by the recipients of new houses is of concern as in many cases; these problems could have been addressed through the design of the structure. Assessments such as the one undertaken by BESG provide insights that can be profitably used in feedback sessions with those responsible for the design and construction of the developments. There is a need for an ongoing process of raising awareness in the built environment professions of the health implications of designs, so as to ensure that the investment made in housing and services does in fact improve the quality of the living environment. Some of the issues raised in the BESG study as well as in the overall report, highlight the important role that local authorities have in the ongoing management of urban areas. This is especially the case in poorer communities where short term costs savings (such as in the capacity of sewers, quality of road surfacing, storm water culvert designs etc) lead to environments which do not perform as well as they might and where mainantence costs are high. In addition, the ongoing management of refuse, repair and maintenance of basic services can make an important contribution to the health of the community. The need for good quality urban management has been identified already as a key challenge for the future of Cato Manor in the conclusion of the Cato Manor Development Project Status Report 2000. The challenge is to make sure that there is an ongoing commitment by the local authority to sustainable management and most importantly that this results in improved quality living environments. 5.3. Urban environmental factors and potential responses: Bradley et al (1992, 7) prepared a table (see Figure 31) showing the typical urban environmental factors and potential areas of action. This has been adapted through adding-in suggested action, drawing from the changed understanding of development, from top down control and enforcement to building capacity to enable a more sustainable community/ household level response.

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Figure 31. Adapted summary of Urban Environmental factors and potential areas of action76

Factor Action Provision Control Education Action Enforcement

of legislation Maintenance Financing Supply

Water ? ? ? ? ? Sanitation ? ? ? ? ? Hygiene Behaviour

? ? ?

Health Care facilities

? ? ? ?

Immunization ? ? ? Vector Control ? ? ? ? ? Garbage collection

? ? ?

Food hygiene ? ? Occupational safety

? ?

Pollution control

? ? ?

Trauma reduction

?

Cooking stoves ? ? ? Shelter improvement

? ? ? ?

Walls improved ? ? ? Crowding reduced

? ? ?

Heating, light, noise

? ? ? ?

Communication: roads, transport

? ? ?

Nutritional provision

? ? ?

Key: The “? ” reflects the aspects identified by Bradley et al and the “? ”, those added by the author.

76 Adapted from Bradley D.J. et al. 1992, A Review of Environmental Health Impacts in Developing Country Cities, A Summary of Urban Environmental Factors and Potential Areas of Action, Table 1-4, p7.

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5.4. Concluding comments Recent research has pointed to a trend for the urban poor being often worse off than their rural counterparts.77 Addressing the underlying structural causes of poverty is a prerequisite to contributing to an enhanced quality of life for the urban poor. Urban environmental health problems are complex and the links between health and physical environment are difficult to separate from causal links with poverty. Nevertheless, intra-urban health differentials are underpinned by poverty and inequity in access to basic services. One of the ways in which inequalities can be addressed is through the provision and maintenance of basic services. Although it has been impossible in this review to directly link ill-health with environmental conditions in Cato Manor, there are a number of known health risks that communities living in the various precincts of Cato Manor are exposed to, to varying degrees. These are typical of low income communities in South Africa and result from inadequate access to basic resources such as water, food, shelter, safe play areas, exposure to hazards such as pollution, vectors and trauma for example. The extensive urban development/upgrading programme underway under the auspices of the Cato Manor Development Association provides a conduit for massive public investment in infrastructure. One of the important (though unstated) outcomes of the initiative would be to improve the environmental health of the community. The achievement in the delivery of houses and services has been impressive. However, this review has highlighted that the investments may not have maximized their health outcomes. A number of problems in the design of the housing and services emerged when assessed from an environmental health point of view. It appears that in housing development programmes, there needs to be a more conscious focus on the health implications of the investment. This may require increased short term expenditure to maximize longer term benefits. The Cato Manor area has reached a stage of development where half of the intended ultimate population is housed on the site. The CMDA has developed the capacity to move ahead at scale to complete the development. This study has highlighted the lack of data on the health of residents other than through the clinic records, a shortfall that can be addressed through an environment, health and wealth baseline study. In addition, the review points to the opportunity for subsequent urban development to take place in a way that consciously promotes the health of the end users. Retrospective action in addressing health hazards in homes should also be taken. The installation of services and the provision of housing however is only one component in the creation of health-enhancing urban areas. The review has highlighted a severe under-provision of environmental health officers based on the national ideal as well as the provincial average. Given the large proportion of low income households living in poor quality conditions, the current staff are unable to address environmental health concerns or to facilitate community responses to the problems. There is a need for health education to play a role in influencing behaviour change. These services should be delivered through a number of avenues, including the environmental health officers and community nurses, schools etc. Current resources limit the potential role that

77 Harpham T., et al 2000, p13.

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health education can play. The ongoing sustainable management of areas is a prerequisite for health and cannot be inappropriately left in the hands of “the community” or the environmental health officers. Local government is responsible for the provision and maintenance of a number of services and should be called to account.

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CHAPTER 6: ASSESSMENT OF THE ALEXANDRA FRAMEWORK AND DISCUSSION ABOUT DATA COLLECTION 6.1. Environment and health indicators developed for Alexandra 1. A preliminary set of 23 core indicators were identified (for further discussion and refinement) in The State of Environment and Health in Alexandra report by Mathee, A., Barnes, B., and de Wet, T. (2000). As background, the selection of the indicators was based on an understanding of the relationships between health and the environment being a complex one with a variety of factors and processes playing multiple roles. “During recent years, a health and environment cause-effect framework has been developed (see Briggs et al 1996) which reflects on the relationships operating between driving forces, environmental pressures, environmental states, human exposures, health effects and actions aimed at minimizing or preventing these effects.”78 The indicators are categorized into environmental exposure indicators such as personal levels of exposure to particulate matter, action indicators which “…may include measures of the provision of water, sanitation and housing, or the implementation of environment and health education programmes. Environmental health indicators may be selected in relation to each of these ‘levels’ in the environment-development-health chain.”79 The selected indicators for Alexandra are listed in Figure 32 in the shaded column. 2. 6.2. Assessment of the Alexandra Framework 3. The proposed categories (ambient air quality, access to safe water, disaster episodes, housing, safety & crime, surface water quality, indoor air quality, socio-economic status, food quality, health, public perceptions) provide a wide-ranging series of factors which impact on health based on an understanding of the complexities of the relationship between the environment and health. When reviewed for use in this study, the indicators were assessed as being of value for the Cato Manor area, which is in many ways at a similar stage of development as Alexandra and experiencing similar driving forces, environmental pressures etc. Thereafter, the data required for use of the indicators was reviewed. Much of the data needed for a number of the suggested indicators, such as ambient air quality, recent crime, surface water quality, food quality, smoking TB, childhood blood lead levels and public perceptions of environmental quality, risks and linkages (see Figure 32) was not available. This does not detract from the value of the indicators but merely points to the difficulty of finding the data to undertake an environmental health assessment making use of specific data.

78 Mathee A., Barnes, B., de Wet T., 2000, p57. 79 Ibid. p58.

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4. CATEGORY

PROPOSED INDICATOR/S

COMMENT RE APPLICABILITY OF ALEXANDRA INDICATORS IN CATO MANOR

AMBIENT AIR QUALITY

Levels of particulate matter (PM10), sulphur dioxide, nitrogen dioxide and ozone in air. VOC Annual noise complaints

Not available

ACCESS TO SAFE WATER

Proportion of households with access to sufficient quantities of safe water

Available

DISASTER EPISODES

Number of homes destroyed/number of people left homeless annually by fire Number of homes destroyed/number of people left homeless annually by floods

Available

HOUSING

Proportion of people accommodated in informal or “unhealthy” housing

Available

SAFETY & CRIME

Number of children/people injured in traffic events Number of cases of murder reported Number of cases of rape reported Number of cases of child abuse

Query availability in view of national clamp down on crime statistics

SURFACE WATER QUALITY

Levels of coliforms in the Jukskei River at Alexandra

Not available

INDOOR AIR QUALITY

Levels of particulate matter in indoor air, VOC, NO2

Data not available but a study has recently been done for a sub area, Cato Crest

SOCIO-ECONOMIC

Proportion of unemployed people Proportion of people without functional education

Reliance on Census 1999

FOOD QUALITY

Proportion of food samples not meeting guidelines in annual surveys

Not available

HEALTH

Number of cases of diarrhoeal disease reported at Alexandra clinics/health centres annually. Number of cases of acute respiratory infections reported at

Yes but Clinic data under-reports on diarrhoeal diseases Yes No

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Alexandra clinics/health centres annually. Proportion of people who smoke Proportion of people with tuberculosis Childhood blood lead levels

Very difficult to know as people seek treatment outside of the study site

PUBLIC PERCEPTIONS

Public perceptions of the state of the environment in Alexandra. Public perceptions of the prevalence of threats to health in Alexandra. Levels of awareness amongst Alexandra residents of the links between the environment and health.

Needs to be assessed through a survey Needs to be assessed through a survey Needs to be assessed through a survey

Figure 32. Adapted version of the Alexandra Indicators table with comments about the applicability in Cato Manor 5.

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6.3 Additional indicators 6. Additional indicators that can be suggested include the infant mortality rate (as an indicator of child survival) – a health indicator, the extent of informal economic activity from home (exposure to occupational health problems) and the use of fuels other than electricity as the main cooking fuel (as a proxy for indoor air quality) – both exposure indicators. While “action” indicators may be difficult to quantify regarding environment and health education programmes, the Cato Manor study has highlighted a severe shortage in the number of environmental health officers deployed in the area in relation to the population of Cato Manor. Based on the difficulty in assessing the effectiveness of the EHO in the area, the crude figure of the ratio of EHOs to the population when compared to the suggested national ratio does provide a very clear indication of the likelihood of environmental health problems being raised or addressed. It is proposed that this indicator be added to the list. 6.3 Data problems 7. The current health risks can be drawn out from the living environment findings and clinic records. The difficulty in the collection of appropriate data on household health, limits the extent to which the health risks can be identified. In addition, the identification of risks also assumes that the data sources (for example the clinic records) are an accurate reflection of the health profile of the community. The hard “quantitative” data can be usefully complemented by other sources of information for example officials working in the area, specific groups in the community who have particular insights, which can add value. The qualitative insights add another facet to the quantitative data. While no primary data collection was undertaken in the study, the following quotes give an indication of how qualitative data can complement the statistics by adding in the human experience component to the description.

“My house is cold and when it rains it leaks and the mud walls fall down," she says. "I don't have electricity, I cook on a paraffin stove and buy my fresh water from the water bailiff, just up the road”.

Clinic data is most useful in environment and health assessments when used to identify the nature of the health problems experienced by the community under consideration. However, it is not always readily available, or if available, it may not be in the most ideal format. In the case of Cato Manor, the clinic data was difficult to obtain and then also difficult to analyze. The data collected was in a format that is not very useful for environmental health considerations. In addition, it was impossible to compare Cato Manor data to data for the district and to the city level data sets. In studies of this nature, clinic data of value would include: ??Morbidity by cause ??Longitudinal data to show (morbidity and mortality) trends over time

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??A profile of those attending the clinic over 12 months ??Data to be broken down by those under 6, those under 14 and the total population ??Ideally, data for those under a year indicates the extent to which severe cases of

diarrhoeal diseases are a problem. ??Causes of mortality, especially infant mortality

The availability of datasets to compare the situation (health and environment) in the settlement concerned with a settlement in a similar area/ stage of development would be useful. They could be used to answer the question, “how does the environment and health profile of the settlement concerned differ from what might have been expected?” This can be used to give an indication of possible health outcomes which could be caused by exposures in a specific area eg, pollution of water bodies, ambient air problems cased by factories in the vicinity etc. Other sources of information about the health of the Cato Manor residents was ascertained through numerous discussions, interviews etc. The EHOs for the area are a source of excellent local knowledge regarding the health and especially the environmental health profile of the community concerned. Neither ambulance nor hospital records were used as these are seldom recorded on a spatially delimited data base. The development agency (CMDA) did not have baseline data for the entire site other than details of individual projects. CMDA had very little health data available. A dearth of an environment and health baseline dataset in Cato Manor proved to be a problem in the overall assessment when compared to the CASE study which was available for Alexandra. In addition, the Census data, while useful and less than 4 years old, was a limitation in Cato Manor as a result of the rapid rate of development of the area. Despite the existence of the CMDA as a urban development vehicle focused on the delivery of basic services in Cato Manor, the lack of overall spatially based data on the range of factors influencing the health of the community levels of services, was surprising. It points to two suggestions. One, the need for environment and health data to be routinely collected as part of baseline studies and two, for environment and health issues to be integrated into the more “hard services-focused” delivery initiatives undertaken at a local government level. For an initiative of the scale and intensity of the CMDA, it may be appropriate to consider how the principles of the Health Cities Initiative, designed for city-level responses, could be adapted and incorporated into their management approach. This would facilitate the consideration of health-linked development issues into the overall development framework. A lack of data for the Cato Manor area itself does not have to be limiting as other sources can also be used. A number of different sources of data were found to be useful which included studies of specific areas of Cato Manor, for example Cato Crest. Although they did not provide quality comprehensive data for the whole site, the data could be used to give indications of possible risk areas/ groups, which could be highlighted as needing to be explored further. The use of spatially linked data sets such as the Census provided a useful resource which needs to be explored further. Using overlay analysis methods to prepare composite

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indicators, it is possible using GIS to identify areas of multiple risk spatially, where health impact studies could be undertaken for targeted interventions. 6.4 Concluding comments The proposed Alexandra Environment and Health Indicators give an excellent baseline position for identifying and assessing environmental risks and exposures. With the additions suggested above, they are seen to be of value for use particularity in low-income urban settlements. It is not possible however to use the set of indicators as a prescriptive tool due to the difficulties in obtaining the comprehensive data set required as well as the need for certain local factors/ conditions to be taken into account. They can however be seen as a valuable guide for use by local government in identifying risks which need to be quantified (through studies). Most importantly, the indicators provide a tool to enable those involved in the provision of health and development-related services to be more aware of the health impacts related to the provision of basic services and the need for inter-sectoral action to address the problems experienced by those living in health compromising environments through targeted investment and programmes.

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REFERENCES …… Britsh NHS Director praises Cato Manor, The Mercury 6.10.1999 Bradley D.J., Stephens, C., Harpham, T., Caincross, S., 1992, A Review of Environmental Health Impacts in Developing Country Cities, Urban Management Program, The World Bank, Washington. BESG 1999. Towards the Right to Adequate Housing, European Union Foundation for Human Rights in South Africa, November 1999. Briggs D., Corvalan C., and Nurminen M. Linkage methods for environment and health analyses – general guidelines. United Nations Environment Programme/United States Environmental Protection Agency/World Health Organisation, WHO, Geneva, 1996. Cato Manor Development Association 1998 Greater Cato Manor Health Plan January 1998 (Final Draft) Cato Manor Development Association 2000 Cato Manor Aerial Views, http://www.cmda.org.za/aerial.htm Cato Manor Development Association 2000 Cato Manor History http://www.cmda.org.za/history.htm Cato Manor Development Association 2000 Cato Manor Key Dimensions, http://www.cmda.org.za/keydimensions.htm Cato Manor Development Project 2000 Cato Manor Development Project Status Report 2000 http://www.cmda.org.za/default.htm Cato Manor Development Association 2000 EA01: Community Health Centre at Cato Manor, Schedule of potential health and community service providers , prepared by M Kaplan, 11.8.2000. CSIR, 2000. Indoor Air Quality Monitoring in Cato Crest, Cato Manor: Raw data. Lead Programme in Technologies for Enhanced Environmental Management, Report no. P5-5, Durban. Durban Environment Health Services, 2000. Summary of Informal Settlements and Development Projects- September Unpublished report for the Executive Director: Corporate Services. Harpham T., et al 2000. Urban Health Review, National Academy of Science, USA. (Draft May 2000)

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Hindson D and Pupuma F 1996 Cato Manor: Report on the State of the Environment and Development in the Durban Metropolitan Area, January 1996, Maharaj R (undated) Evaluation of Low Cost Formal Settlements and Informal Settlements from an Environmental Health Perspective, Prepared by the Industrial Health Unit, University of Natal, Medical School for the Built Environment Support Group.(unpublished) Mathee A., Swanepoel, F., Swart, A., 1999 Environmental Health Services, Chapter 20 in South African Health Review, HST. http://www.hst.org.za/sahr/99/chap20.htm. Mathee A., Barnes B., De Wet T., 2000, The State of the Environment and Health in Alexandra, Commissioned by the CSIR. Mitlin, D., Satterthwaite D., et al. 1996. “City Inequality” in Environment and Urbanization 8(2): 3-7. Msomi S …..Shoddy work angers housing scheme residents, Daily News, 19.7.2000 Mugonda M One man contract system for community waste management Cato Crest, Durban, Unpublished MSc Thesis, School of Life and Environmental Sciences, University of Durban 2000 Ngubane P Minister hits the roof at housing inspection, The Mercury 18.7.2000 Oelofse C Environmental Considerations in Low Cost Housing projects, report for BESG, December 1999. Prabhakaran S Cato Manor on the fast track, Weekly Mail and Guardian 28.8.1998

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Thomas E.P., Seager J.R., Viljoen E., Potgieter F., Rossouw A., Tokota B. and McGranahan, Kjellen M. Household environment and health on Port Elizabeth, South Africa. Urban Environment Series Report no. 6. Stockholm Environment Institute, South African Medical Research Council and Sida, 1999. World Health Organisation, Health and Environment in Sustainable Development – five years

after the Earth Summit. WHO, Geneva, 1997.

World Health Organisation, Our Planet, Our Health, Report of the WHO Commission on Health and the Environment, Geneva, 1992.