9. Public facilities - schools, health care, hospitals -

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1. Scope

2. Environmental impacts and protective measures

2.1 Educational and training facilities and their environment

2.1.1 Impacts on projects from the natural environment
2.1.2 Impacts on the environment from the man-made environment
2.1.3 Impacts on the environment from projects
2.1.4 Protective measures and recommendations
2.2 Health care facilities and their environment

2.2.1 Impacts from the natural environment

2.2.2 Impacts on the environment from the man-made environment
2.2.3 Impacts on the environment from health care facilities, particularly hospitals
2.2.4 Protective measures and recommendations

3. Notes on the analysis and evaluation of environmental impacts

4. Interaction with other sectors

5. Summary assessment of environmental relevance

6. References


1. Scope

The measures dealt with in the present environmental brief have to do with the provision of what is also known as "physical infrastructure". Their goals lie in the creation and development of facilities

- for education and training
- and health care

and thus in two areas of primary importance for the public and private provision of essential services.

The present brief does not go into the philosophy of environmental education but the importance of such education should not be overlooked.

Education and training covers projects both in the field of education and training for children and young people and in the field of adult education and training. In both cases, the main focus needs to be on education and training to instill and develop job skills.

The field of health care falls into two sub-divisions:

Improving hygiene and prophylactic health care (e.g. immunisation against infectious diseases) and providing health education and advice. Particular activities which come under these headings include advising on diet and the family, creating and developing facilities for nursing and supply such as facilities for supplying the disabled with drugs, and the training and deployment of medical personnel. In the present brief it is projects that fall within the field definable as "planning, construction and running of education, training and health care facilities" that are considered from the point of view of their adverse environmental impacts.

The impact of projects in the field of health care, education and training is to alter the structure of a country and not least the thinking and feelings of its people and their conception of themselves. It seems essential to proceed with, above all, due consideration for

- the special ethnological character and diversity of the given country and its different ways of life, commercial and industrial practices and modes of behaviour, its understanding of nature and the environment, and its cultural and religious traditions,
- the perceptiveness and comprehension of the people concerned, and
- their willingness to act to meet the demands of changes that are environmentally relevant.


2. Environmental impacts and protective measures

The environmental impacts that can be expected to occur during the planning, building and use of educational, training and health care facilities can be classified by their differing causes:

- impacts on projects from the natural environment,
- impacts on the environment generated by projects.

These different impacts will be looked at in detail below, and also described will be protective measures (see sections 2.1.4 and 2.2.4) that can be adopted to moderate, compensate for or even totally avoid adverse environmental impacts when planning, building and using educational, training and health care facilities.

2.1 Educational and training facilities and their environment

2.1.1 Impacts on projects from the natural environment

The factors which should be covered in a study in this case are the following:

- topographical conditions (e.g. mountainous, desert or marshy terrain, lagoons),
- climate (e.g. wind directions and strength, pollution by dust and sand, solar radiation, humidity, air circulation),
- location and ground conditions (e.g. soil strength, risk of earthquakes and volcanic eruptions, marshy areas, areas subject to flooding),
- fauna (e.g. prevalence of fauna that cause or transmit disease such as the anopheles mosquito, tsetse fly, black fly, rats, poisonous snakes, etc.).

2.1.2 Impacts on the environment from the man-made environment

These environmental impacts take the form of noise, and air, water and soil pollution. They are generated by traffic, industrial and commercial areas and private households, and by agricultural production, the generation of energy and the disposal of wastewater and solid waste.

2.1.3 Impacts on the environment from projects

Environment impacts on the natural environment that result from training and educational facilities are caused by:

- land uptake,
- sealing (of the ground surface by concrete, asphalted areas etc.),
- traffic (as a result of development, stationary traffic),
- solid waste,
- water pollution,
- noise (machines, equipment and concentrations of human beings).

Training and educational facilities having particular environmental relevance are:

- schools with teaching laboratories,
- training centres providing job training,
- laboratory and research facilities providing training in engineering, chemistry, biology, medicine and physics.

If they are incorrectly mounted or misused, the use of laboratory materials and equipment and teaching aids (chemicals, technical equipment and machinery etc.) may produce physical and chemical changes in the air, groundwater and soil whose severity and extent is difficult to control (see the relevant brief in this connection).

Sports facilities, which are generally sited close to schools, exert environmental impacts over and above those of the schools themselves due to:

- the levelling (and often the sealing over) of relatively large areas of land,
- changes in the soil conditions caused by stripping of the top soil and laying of a new soil profile,
- additional noise emissions,
- a demand for extra energy and land for transport purposes.

New types of educational and training curriculum and the resulting changes in the educational and training organisations may also bring changes in social behaviour with them.

2.1.4 Protective measures and recommendations

Protective and corrective measures to mitigate or prevent adverse effects on the environment will be needed when the location of training and educational facilities is being decided and while they are being constructed and run.

Ÿ Determining location

Educational and training facilities for providing a basic education inside or outside schools are considered part of the residential infrastructure and need to be erected within easy reach of housing, normally inside residential settlements.

When new residential settlements are being planned, the setting up of the residential infrastructure generally forms an integral part of the scheme. In this way, important prerequisites for environment-friendly location fixing have already been met, such as availability of connections to supply and discharge pipes and cables (for water, wastewater and energy), incorporation in the footway and road network, availability of building materials, etc. It is important to avoid locations for training and educational facilities, and hence for residential settlements, where there are hazards to the project arising from geological, topographical or climatic conditions or from fauna (see section 2.1.1). Also to be ruled out are locations that are subject to industrial or commercial emissions, that are adversely affected by traffic, energy producing plants or agricultural production, or that present a particular potential hazard due to the absence of facilities for disposing of wastewater and solid waste or their closeness to waste dumps (see section 2.1.2). The location of a facility within residential settlements, and also within rehabilitation areas, must be selected in such a way that the facility is easy to reach, i.e. only a small amount of time and money has to be spent on the journey to it. At the same time, the location selected must be such as to ensure that the noise, traffic and other adverse effects caused by the facility itself at least remain within reasonable limits (see section 2.1.3). The main thing that needs to be established when existing residential areas are to be provided with educational and training facilities is whether it is justified in the medium or long term for the provision to be made in situ, i.e. a check must be made to see whether it is possible for the residential area to remain where it is in view of its position in an area at risk from the natural or man-made environment. If educational and training facilities are to be provided for residential settlements in areas subject to environmental stress, alternative locations will have to be found for the facilities. These should not only ensure low levels of environmental stress but should also ensure that the facilities can be reached easily in the long term by the population for whom they are provided.

Ÿ Protective and corrective provisions in design and construction

By means of the overall project design and the way in which the plot of land is used, and by the division into blocks and the positioning of the blocks on the plot, it will be possible, to a large extent, to guard against incoming adverse effects from the outside environment. At the same time it will be possible, within certain limits, to so arrange the design as to avoid or reduce any adverse outgoing environmental impacts from the project.

The use and refinement of customary local principles of design and building materials can make a further contribution to the environmentally acceptable installation of educational and training facilities, provided the following criteria are met:

- a better microclimate at the location, achieved inter alia by using traditional artisanal skills,
- fitting out to suit the climate.

Sanitary areas in schools should be so designed as to ensure that environmentally acceptable disposal of an adequate volume of material will be possible in the long term. Schools with laboratory facilities (see section 2.1.3) should be designed with a particular eye to the greater risks they pose to the environment (due to toxic materials finding their way into the sanitary area and to misuse and incorrect mounting).

When laying out the grounds of schools and the associated sports grounds, the following points need to be borne in mind:

- avoid the need for large amounts of water or energy to be used for the laying out or for future upkeep,
- prevent any soil erosion,
- avoid bodies of dormant water and areas of plant life likely to attract insects that are undesirable on health grounds.

2.2 Health care facilities and their environment

2.2.1 Impacts from the natural environment

It is the natural conditions of existence that mould the way of life, behaviour and modes of economic activity of human beings. Among the determining factors are weather conditions, which vary with the seasons and the given climatic zone, availability of water, and changes in flora and fauna in response to climate and water (see section 2.1.1). These factors form the defining conditions for the health, well-being, fitness and diseases of human beings. Particularly at risk is the health of people living in regions where the pathogens causing malaria, cholera, bilharzia and onchocerciasis can be found in marshes, swamps, rivers and bushlands. Environmental impacts likely to be harmful to building projects in the health care field can, in the main (see section 2.1.1), be generated by topographical, climatic and locational conditions and by fauna-related factors.

2.2.2 Impacts on the environment from the man-made environment

To an increasing extent, adverse effects on health are being caused by
- pollution of ground and surface water,
- soil contamination,
- air pollution and
- biogenic impact paths (build-up of pollutants in plants, animals and the human body).

Some examples that can be cited in support are as follows:

1. Evidence of chemical pollutants in water and food,

2. Increasing stress from air pollutants and smog, particularly in large conurbations but also in rural areas, and the frequent recording of cases of chronic bronchitis and asthma attributable to exposure to smoke and dust. What affects health is, above all, the building infrastructure. The main impacts involved here are ones caused by

- poor housing conditions,
- the non-availability of food, water or fuel, and
- lack of facilities for disposing of wastewater and solid waste.

2.2.3 Impacts on the environment from health care facilities, particularly hospitals

As well as land uptake and ground sealing, it is likely that there will be environmental impacts from impacts on the soil caused by buildings and work done on the terrain, and by the pouring away of liquids and the dumping of solid waste. Surface water may be affected in similar ways. Air pollution can be expected both from the services infrastructure of a health care facility as a result of waste air, combustion processes and solid waste, and it can also be expected from cleaning agents and disinfectants and materials that release vapours harmful to health. Consideration should be also given to indirect impacts and delayed impacts on humans, flora and fauna. These may result from direct contact or may operate via impact paths such as build-up in the soil, infiltration into groundwater abstracted as drinking water, and so on. It should be borne in mind that as the facilities in question increase in size, additional stresses arise as a result of the traffic generated, such as noise, dust, safety risks and further land uptake.

2.2.4 Protective measures and recommendations

The multiplicity of interactions between modern day health care and the environment make it necessary for protective and corrective measures to be implemented at different levels. Outlined below are measures of this kind for fixing the location of health care facilities and for planning, building and running them.

Ÿ Requirements to be met by the location

Health care facilities are part of the residential infrastructure and as such should be sited close to dwellings, i.e. in residential settlements. It is advisable for the copiousness of provision to be geared to requirements, with facilities for primary medical care well spread out over large areas. Regional health centres and main and specialist hospitals should then be inserted in this network. One of the things on which the effectiveness of such health facilities will depend is their locational characteristics, among which is whether they are reachable by the population being cared for.

The requirements to be met by the location of a facility result from the purpose for which medical and nursing care is administered. As a rule, locations subject to no immissions or only low levels should be selected. The availability of water of good quality in adequate volumes must be guaranteed. A reliable energy supply, normally meaning a connection to an electricity supply network, and provisions for emergency backup will be needed, as also will connections to the existing public wastewater drainage system and organised disposal of solid waste. Care must be taken to see that the facility is within reach for emergency medical care. Locations need to be suitable for transport (for linking up with roads and if possible bus and, where appropriate, rail services). The need for supply and disposal infrastructure will very much depend on the nature and scope of the medical care provided. If a dedicated wastewater discharge system has to be provided, as it will in the majority of cases, the wastewater should always be treated first and only then discharged into rivers. Other criteria governing the choice of a location are:

- land uptake by the planned facility and by the existing or developable facilities at the location,
- whether deleterious environmental impacts can be avoided at the location by appropriate building practices, use of buildings, and planting,
- zones containing breeding grounds for insects that constitute a health risk should not be selected, or reasonable remedial steps should be taken.

Ÿ Structural protective and corrective measures

Buildings for health care facilities need to be developed in the light of medical, hygiene and organisational requirements and should be adapted to climatic conditions at the given location. Environmental impacts may stem as much from the interior of buildings as from the exterior.

Toilets in health care facilities, and the more sophisticated sanitary arrangements in their treatment areas and laboratories, should be designed to meet the requirements of hospital and environmental hygiene. Isolation wards, and primary health care facilities that are called upon to act briefly as isolation stations to avoid any direct or indirect risks, will require additional expenditure on more than the normal scale (to provide dedicated sanitary arrangements, sterilisation units, suitable screening, etc.).

The size, layout, boundaries and use of the grounds, the positions of the buildings and the nature and extent of the plant cover all have a bearing on many of the impacts caused by the environment, such as the action of sunlight and shade, humidity, wind, and dust, though planning, structural and architectural provisions may alleviate such impacts or even, in some cases, make beneficial use of them (e.g. solar energy).

The solid waste and liquids generated by health care facilities, e.g. cleansers, disinfectants, laboratory liquids, pharmaceutical preparations, waste materials from radiotherapy (radioisotopes), need to be classified on the basis of their environmental implications. The problem of disposing of the solid waste and wastewater generated by hospitals and other facilities connected with health care and doing so reliably and in an environmentally acceptable way will generally need to be treated, at the outset, as a problem of special waste. Whether incineration, composting or dumping on rubbish tips is best will depend on local conditions and on the nature of the waste, how it is held before final disposal, and the transport and disposal facilities available. Radiology departments and radiological protection in large hospitals and specialist clinics are always a special case.

The highly infectious waste from hospitals is a particular hazard and one which is aggravated by suitable climatic conditions (heat).


3. Notes on the analysis and evaluation of environmental impacts

The environmental impacts caused by schools providing basic education are generally so slight as not to require any particular analysis. The fundamental prerequisite here is planning that is environmentally aware and gives due consideration to ecological requirements. In the case of sports facilities and schools providing vocational training and education, it is advisable for a separate analysis and evaluation of environmental impacts to be made.

To keep the impacts caused by stresses on the environment down to innocuous levels, it is necessary for reliably maintainable threshold values for pollutant concentrations to be established from sound toxicological and epidemiological evidence and laid down.

Important pointers, often indeed the only pointers, for evaluating the stress on air, water and foodstuffs caused by pollution are provided by the recommendations developed by the World Health Organisation (WHO) which are embodied in its "Health Criteria".

The development and application of country-specific standards is felt to be essential. However, where similar conditions exist in other countries, it may be helpful for experience in dealing with pollution standards to be compared and contrasted.

The guidelines and statutory codes that apply to German conditions are based on a largely self-contained system of laws and regulations. The main provisions are laid down in the Bundes-Seuchengesetz [Federal law on infectious diseases], the Wasserhaushaltsgesetz [Federal Water Act] and its supplementary provisions applicable to individual German states, the Abfallbeseitigungsgesetz [Waste Avoidance and Waste Management Act], the Abwasserabgabengesetz [Waste Water Charges Act], the Bundesimmissionsschutzgesetz [Federal Immission Control Act] and TA-Luft [Technical Instructions on Air Quality Control]. Another source of information is EC directives.

In Germany, the recommendations and guidelines for building schools and hospitals include specific planning and construction notes that reflect legal requirements and the requirements of the German construction supervisory authorities. For projects in other countries, the existing law will need to be checked for references to the environment. These may provide some points of departure for advice provided by institutional bodies. Studies of typical facilities for providing primary health care and their potential environmental impacts show that simple, environmentally compatible solutions are perfectly feasible, provided that environmental questions relating to planning, execution and operation are considered at an early stage. In the case of large facilities, and particularly hospitals of regional status and hospitals with specialist departments, amplificatory analyses will always be needed to allow environmental impacts as a whole to be evaluated. The wastewater from German hospitals has been classified as medium-hazardous. Generally speaking, waste disposal from hospitals should be treated as a matter of disposing of special refuse. Another special question is the radiology departments in large hospitals.

However, land and water have a natural self-cleansing ability to deal with certain pathogenic organisms and this will help in allowing simple methods of disposal and treatment to be employed even in tropical and sub-tropical climates. What is crucial though is that there must be no interference with this process of natural degradation and that the process must not create any hazards of its own before it is complete.


4. Interaction with other sectors

The "Schools" sector is linked in a crucial way with questions of schooling provision in regional, urban and rural development programmes.

In urban areas, locational questions relating to schooling facilities in projects such as

- rehabilitation of urban districts (slums, squatter areas),
- sanitation, and
- provision of sites and services,

are likely to be cross-related in significant ways with town planning, development of residential areas and rehabilitation (see also the environmental brief Provision of Housing). It is essential for the present sector to be geared to other infrastructural sectors such as rural and urban water supply and wastewater disposal. Where the appropriate institutional framework exists, close co-ordination is advisable with departments responsible for environmental protection.

Close ties will also need to be established with regional, urban and rural development programmes when facilities for providing primary health care, hospitals, and other facilities connected with the provision of medical care are going to be built. This will affect not only the provision that is made for public health care and the matter of suitable locations in towns, but will also call for interaction with sectors relating to the services infrastructure. More detailed notes on disposal questions will be found in the environmental briefs Analysis, Diagnosis and Testing and Disposal of Hazardous Waste and in Vol. III Compendium of Environmental Standards.

For simple, effective and apposite answers to constructional and technical questions relating to facilities for primary health care, it is advisable to look at what has been learnt in the field of "appropriate technologies".


5. Summary assessment of environmental relevance

In the present sector, environmental implications can be obtained in a form in which they are comparable by

- adopting the same division as is applied to the provision itself, namely primary provision, provision of main centres, and provision of special units and considering the environmental implications of each of these, and
- by adopting location-related criteria.

The improvement of schooling and health care is often felt to be a sine qua non for encouraging general development processes tending to produce better conditions of life.

Whereas schooling facilities generally exert easily assessed and only slight impacts on the environment, the sports facilities associated with schools, and schools with special laboratory facilities, particularly schools giving vocational training, require closer scrutiny for any possible environment impacts. In the present sector, there will not normally be any need to develop requirements for environmental protection which are not already embodied in the sector's own rules for environmental design.

In the case of hospitals and other facilities assignable to the field of health care, there will always need to be a separate investigation into any possible adverse environmental impacts caused by risks of infection.

Planning approaches that are particularly geared to environmental requirements but cost-conscious at the same time are feasible for projects of both kinds.

The locations of the facilities will be determined by planning objectives such as a wide measure of freedom from immissions, a good microclimate, and easy access. The environmental impact of the facilities on the location and its environs should be looked at.

Simply because of its underlying assumptions, the health care sector has major implications for the environment. The relevance to the environment of steps taken in this area lies mainly in the indirect and consequential impacts of these steps. In the light of their possible "negative or positive feedback", it seems all the more important for such impacts to be studied and for attention to be focussed on the subsequent action that can be taken in response to them.

With projects of both types, consideration needs to be given both to general interactions with other sectors and to interactions which need to be looked at from a variety of points of view. Full advantage should be made of any opportunities to adopt a unified approach.


6. References

Bundesgesundheitsamt [German Federal Health Office]: Die Beseitigung van Abfällen aus Krankenhäusern, Arztpraxen und sonstigen Einrichtungen des medizinischen Bereichs, Zfa-Merkblatt Nr.8, 1974.

Einleitung von Krankenhausabwasser in Kanalisation oder Gewässer, Merkblatt, 1978.

Diesfeld, H.-J., und Wolter, S.: Medizin in Entwicklungsländern, Handbuch zur praxisorientierten Vorbereitung für medizinische Entwicklungshelfer, Band 19, Heidelberg, 1984.

Flahault, D.M. and Roemer, M.J.: Leadership for primary health care levels, functions and requirement based on twelve case studies, Public Health Paper, No.82, WHO, 1985.

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