Source document: https://docs-lawep.s3.us-east-2.amazonaws.com/1694840539022.pdf (Malta)
IT-TLETTAX-IL LEĠIŻLATURA P.L.

4413 Dokument imqiegħed fuq il-Mejda tal-Kamra tad-Deputati fis-Seduta Numru 294 tat-3 ta’ Frar 2020 mill-Onor.

Godfrey Farrugia, MP.
___________________________ Raymond Scicluna Skrivan tal-Kamra A HEALTH IMPACT ASSESSMENT : latest A healthy Gzira by a Manoel Island project Godfrey Farrugia MD, MMCFD,MP Content Introduction The Physiognomy of Gzira The Determinants of Health The State of Physical Environment of Gzira Health Equity Conclusive remarks Data Sources INTRODUCTION All urban areas whether they are cities, towns or villages, have a distinct environmental, social, cultural and economic dimensions that make them unique.
It is these dimensions that have an impact on the individual and population health and wellbeing.

The objective of this Health Impact Assessment (HIA) is to to assess and address the impacts of the Outline Development Permit of Manoel Island's project in relation to its locality, Gzira.

The overarching intention is to place health and wellbeing high on the agenda of Gzira.
THE PHYSIOGNOMY OF GZIRA Gzira, which includes Manoel Island, ( 1 kmj sq) is centrally located, neighbouring Sliema, Ta' Xbiex, Msida and Kappara, forms part of the Northern Harbour Region on the Marsamxett site of Valletta.

It has no rural confines and boasts of a short sea-front promenade that faces Manoel Island.

This island, which occupies a surface area which is approximately one third of the locality, has given the name to the locality, Gzira (island).
It has an estimated population of 9222 to 10784 (no official census is available) with a population growth of around 4°/o per annum.

These characteristics hallmarks Gzira as one of the most densely populated urban areas.

Up to 2010 the population of Gzira was declining and had reached the 7000 mark.

Many were its sons and daughters who left town to other parts of Malta, leaving behind a more elderly residential population.
The recent rise in population is attributed to foreigners who are residing in this town because of its proximity to office work in Sliema, Ta' Xbiex and Gzira itself, to the University and to Mater Dei's hospital services.

This has made Gzira a multicultural town, with a fairly integrated community.

Gzira does not boast of any squares, pedestrian zones or connected pathways and its parish church is tucked away in one of its streets surrounded by a small village core.
The town which may be considered as a suburb of Sliema is mushroomed with residences and does not have a sprawl.

The few residences that have their own private gardens or front gardens are easily counted, and most court yards that certain homes had, have been incorporated into new development to maximize on building space.

Gzira is undergoing a phase of rapid vertical urban development as no land space is available.
In so doing it is loosing its traditional charm to a modern Gzira, that hosts a business community of hoteliers and restaurants, financial and legal institutions.

Most Gzira residents live in apartment blocks.

There is no official data in the public domain that state the unit ratios for residences, office space and entertainment spots in Gzira.

This would be indicative of the locality's (and Malta's) sustainability in relation to the proposed project.
Despite this Gzira is generally acknowledged to be a residential area.

Once Manoel island is developed the number of residences will be increased by 640 units.

This would mean that the residential population by this project alone, will increase by approximately 1850 residents.

One must also take into account that this project includes a hotel and a retail and catering area described as a luxury high end.

Manoel Island( 0.3 Kmj sq) is a historical gem.


Its magnificent Fort Manoel (1723) and Lazaretto( 1592) are testimony.

The fort is part of our national patrimony.

Manoel Island enjoys greenery, open sea and harbour views on the sides of its two creeks, and a picturesque Marsamxett landscape.

In recent years its general upkeep has been one of neglect and also disgraced by dilapidated buildings.
Manoel Island bears the name of Grand Master Antonio Manoel de Vilhena}is the principal relaxation area for the locality's population} more so for the children who were brought up in Gzira.

A duck village is an added attraction and many are the Maltese families who stroll in in islands green and sea shore pathways.

It also hosts a yacht yard and a yacht marina with around 350 berths.
Gzira's open public spaces} apart Manoel Island} are Council of Europe Public Garden and the sea front promenade along Xatt ir-Risq.

Greenery is limited to these areas.

There are no avenues and no out-door sports facilities or children's play grounds.

Land space is scarce} and more so public space.


It is noted that the Council of Europe Public Garden space is to be reduced, as Gzira's fuel station which is situated adjacent to the bridge to Manoel Island is to be re-allocated to this area and a yacht marina Capitanerie is also to be built.

Furthermore this Outline Development Permit will decrease Gzira's promenade with the building of a new and larger Manoel Island bridge.
Part of Sliema creek is to be reclaimed (10,299mjsq), thus decreasing the creek, and also bringing the Yacht Yard and its industry closer to the other bank.

The Gzira shoreline is to be conceded to private entities to establish a lido and to increase the number of yacht marina pontoons on the Council of Europe Garden side.

Fishing and boating is a very traditional pass time in Gzira, as its creek is part of Marsamxett harbour.
Moreover the slip way and the space reserved for small boats when stored on dry land, which are the only ones along the entire length of Sliema creek are to be removed.

So are the buoys and berths of the local hobbyist, fishermen and owners of small boats at Gzira.

Poorly planned Gzira has over time been turned into a residential glorified traffic island.

This is a consequence of the growth of Sliema, St Julians, Paceville and the surrounding neighbouring localities.
It's habitat has been fragmented by Regional Road, RueD' Argens and Triq ix-Xatt and a network of grid like roads that interconnects the Central Region through its urban streets.

This is the consequence of unco-ordinated town planning between different entities and poor policy frame works by governments.
To make matters worse the District Health Centre and two schools, one public and another private which receives students from all over Malta, are situated in Gzira's residential hub, thereby increasing traffic congestion.

This recommended development targets the locals' civic pride, community ownership and identity.

Manoel Island no longer belongs to them.

Apart from the village feast, Manoel Island is regarded as the sole and identity of Gzira.

The proposed project is described as : gentrifying Gzira.
Is this the way forward for Gzira, which is hallmarked by an unhealthy environment and health inequality?

Conclusion: The urban characteristics of Gzira are indicative of a human habitat which is not conducive to the better health and quality of life.

Gzira is suffocated and this project will undoubtedly increase the existing health inequalities.
The denser the urban population the more negative the impacts on the environment and the bigger the effects on the health and the quality of life of the population.

To make matters worse, Gzira's town planning has developed this urban habitat without effective consideration of its functionality and beauty to the detriment of health and wellbeing.
The Outline Development Permit of PA/9407 /17, and for that matter other similar projects, does not cherish the public good and common interests of the present resident population, as the locality does not and will not be guaranteed an improved healthy living.

The next section of this paper will state why?

THE DETERMINANTS OF HEALTH All cities, towns and villages are first and foremost a human habitat.
Human health should be the prime focus and the rationale on how urban ares are planned, developed and improved prior to other considerations, including economic growth.

Urban planning and urban health cannot develop in separate tracks (Harpham & Tanner, 2014).

Gzira is such a prime example where urbanization took the wrong path.

This is a consequence of maladministration and bad governance.
A number of recent policy documents from UN HABIT A, the World Health Organization and other bodies are recommending new approaches to manage and enhance healthy urbanization, and address major health challenges, focusing more on understanding causes and prevention, than on medical intervention and treatment.

It is time that the Panning Authority places health and health equity at the centre of urban planning.
Health is a state of complete physical, mental and social wellbeing and not merely the absence of disease or infirmity.

(WHO, 1948) Rightly so, this defines a broad definition of health.

It is the natural, built and institutional elements of an urban environment that determine the physical, mental and social health of the people who live in a locality.

There are many factors which may affect the health of individuals and communities.
People's health may be determined by genetic pre disposition, the state of the environment, ones income and education level, ones habits and ones relationships with friends and family members amongst a number of variables.

The more commonly considered factors such as access and use of health care services have less of an impact.
The determinants of health are: -the social and economic environment -the physical environment -a person's individual characteristics and behaviours By far the physical environment where people live and work is a crucial determinant which is not under the direct control of most individuals.

The physiognomy of Gzira is a negative determinant to health.

The health and quality of life of the citizens of Gzira have been jeopardized and this outline development application will only increase these concerns.
Conclusion: It is important that the urban design of this Outline Development Permit approaches urban health and urban planning by effective, holistic integration, so that Gzira's community, which has poor urban health qualities, also benefits from this mega- project.

This should be viewed as a symbiotic relationship where added value is given to the urban health of Gzira.
What has been proposed in the Outline Development Permit application will only reinforce the established and significant health inequalities of Gzira, when compared to other localities.

THE STATE OF PHYSICAL ENVIRONMENT OF GZIRA The physical environment refers to the external, tangible surroundings in which an individual or a community lives in and which can influence ones health and wellbeing.
Factors in physical environment that are important to health include: 1. harmful substances e.g.air pollution or proximity to industrial sites 2. access to various health-related resources e.g.recreational resources 3.community design and the built environment e.g.

land use mix, street connectivity, transportation systems Malta's environmental health inequalities are well documented ( Environmental Health Inequalities in Malta 2013).
The environmental status for 2009 to 2015 is also well described ( The State of Environment Report 2028).

Since then a number of years have elapsed, and it is acknowledged that the noted discrepancies have in-fact worsened.

These include : • the impact of our 'car culture', and the increased levels of noise, air pollution and car accidents • the growth rate of Malta's population is the highest among EU member states.

This is a result of immigration by foreign nationals.
Moreover, Malta's population is aging and projections show that this will increase further.

• the high cost of housing and rental accommodation affecting the ability of citizens to own their own homes, which in return is leading to increased overcrowding within homes.

• a decrease in our natural capital combined by a fast forward urban development that includes increased heights of buildings.
These national environmental stresses on urban health have ramified through all our localities but the situation in Gzira is singular and worst than most localities because of • a high density population which is a characteristic of the Northern Harbour Region • regular high traffic inflow and traffic congestion, which increases in the tourist season • poor urbanization A considerable body of international literature has demonstrated that residents living in inner city areas tend to be more exposed to air pollution, light, noise and traffic accidents than their suburban counterparts.
High traffic neighborhoods, made worse by a scenario of densely populated locality is a primary characteristic of Gzira.

It is these traffic induced hazards that synergistically increase the health risks of Gzira residents.

Moreover crowded and dense urban localities mean that a higher proportion of transportation takes place within a limited geographical area, more so in a maize of one way streets.

Seen in isolation, this increases the concentration of pollution.
Air Pollution One very common and fairly obvious negative aspect of highly congested urban areas is air pollution ( OECD2012b).

Air pollution is defined as any harmful substance being suspended in the air.

As climate change and pollution proliferate, illnesses caused by environmental factors are on the rise and the medical professional is increasingly warning people about the growing health consequences.
({Air pollution is synonymous to high environmental health risks, contributing to premature mortality and an increase in the incidence of diseases, and WHO attribute approximately 7 °/o of Malta's 2010 mortality, and the loss of 3,606 disability adjusted life years (DALYs) to ambient air pollution".
(The State of Environment Report 2018) Ambient air pollutants are likely to characterise indoor air pollutants, which include nitrogen dioxide(N02), sulphur dioxide(S02), ozone (03) and carbon monoxide(CO), volatile and semi volatile organic compounds, particulate matter(PM) and microorganisms.

The main culprit is traffic flow and congestion, which is being exacerbated by a continued annual rise of registered vehicles in the streets.

See photo I.
See photo I.

To reproduce image Data is available in real time on ERA's website for BTEX, ozone, particulate matter, sulphur dioxide and nitrogen dioxide.

The closest monitoring station to Gzira is in Msida.

Throughout the year international standard guidelines are occasionally exceeded for Gzira particularly for the concentration of airborne PM and N02.

This is attributed to the heavy traffic flow.


It is perceived that if the latest periodic indices of air quality for Gzira are published these will be worse than those of previous years, as the traffic problems have increased dramatically.

There are other parameters which must be considered even though they are minor contributors to air pollution : a) The Yacht Yard at Monoel Island is to be expanded and the Outline Development Permit proposes that it is sited nearer to Triq ix-Xatt on reclaimed land.
This yacht yard can accommodate yachts of up to 50 metres in length.

It offers boat storage, berthing afloat, repairs and complete refits.

This industry and its trades are also a source of pollution of other air contaminants.

b) The sliema creek is a venue of frequent tourist and leisure boat trips powered by highly polluting diesel engines.
Moreover most ships and cruise liners visiting Grand Harbour are known to be heavy air pollutants and depending on wind direction, their plume's fall out will also reach these areas.

This ongoing sea traffic adds to the contamination of air.

c) Making the channel between Sliema and Lazzaretto creeks navigable will enable leisure boats to pass from Gzira waterfront where it is not possible right now.

This will continue to add air pollution to the Trig ix-Xatt area.
Malta's mean air temperature shows a local warming trend of +0.22oC per decade, a total annual precipitation of 553.1 mm and 2,954 hours of bright sunshine.

This corresponds to a hot and dry archipelago.

Such weather conditions potentiate air pollution.

Moreover the way forward in Gzira' s local plan is for high streetscapes.
These are characterised by poor ventilation, as high buildings without adequate street space creat a ~street canyon', thus reducing air dispersion and trapping outdoor and indoor air pollution within the urban confines.

It is not my intention to give a detailed account of the each pollutant's heath hazards by quoting medical scientific literature.
Quoting ERA champions ones objective : t{Documented related health impacts include: cardiovascular diseases; impacts on the respiratory system; atopy - irritation of eyes, nose, throat and skin; headache and anxiety; impacts on the central nervous system; impacts on the reproductive system; and impacts on liver, spleen, and blood."

(The State of Environment Report 2028) See photo 2.

To reproduce image Air pollution is a definite health hazard for Gzira's residents.

Most vulnerable are children.


SINPHONIE (Schools Indoor Pollution and Health: Observatory Network in Europe) compliments studies of asthma and allergies in childhood undertaken in Malta ( Fsadni Peter).

These studies show a high prevalence of recurrent wheezers and other related respiratory disorders, especially in classrooms that face roads with a flow of heavy traffic.
This is an eye-opener not just for schools, but for those children who live in homes which are engulfed by the traffic of Gzira for most of the day.

The project as described in the ODP will not only further stress Gzira' s transport management permanently, but during its building stage which is projected to take between seven to eight years, the flow of the heavy traffic will be increased drastically.
Conclusion: The benefits of cleaner air contribute to reduced health services costs, and increased life expectancy.

Residents of Gzira have an increased morbidity and mortality when compared to other localities (a health inequality) .

Noise Pollution Eurobarometer surveys show a public outlook that noise pollution is an urban problem in Malta.

Noise is an unwanted sound.


Environmental noise, also known as community noise, is defined as noise emitted from all sources except from industrial workplace(WHO).

In the case of Gzira the source is traffic related.

It is an established fact that air and noise pollution share the same sources.

The expansion of the yacht marina both on Manoel Island and on the garden side together with the yacht repair yard will increase noise pollution.
Masts and rigging are notorious for the noise generated even with a moderate wind.

WHO acknowledges noise as a threat to public health due to its harmful effects on human health and has quantified the burden of disease due to environmental noise exposure.
There is sufficient scientific evidence that noise exposure can induce a direct effect as in hearing impairment and tinnitus; physiological stress as in annoyance and poor school attention; and physiological effect as in ischemic heart disease and hypertension.

Noise also acts as a nonspecific stressor on chronic disease or less healthy life styles.

EU Environmental Noise Directive is an instrument to identify noise pollution levels and to trigger the necessary action both at Member State and at EU level.
Our national laws are very weak.

No statics are available in the public domain.

Society is unprotected.

Light Pollution Light pollution is the presence of anthropogenic and artificial light in the night environment.

Excess light has a wide range of negative effects on human health such as disrupting the circadian rhythm and melanin system.

Disruption of these rhythms can result in insomnia, depression, an increase risk of breast cancer, and cardiovascular disease.
Gzira is not heavily light but the ongoing traffic till late at night, the direction being taken to commercialize the locality and the high buildings that are littering an urban environment have an added negative effect to health.

Furthermore, this ODP is seeking to build apartment blocks equivalent to 9 to 10 floors on reclaimed land from the Sliema creek.

If precautions are not taken the light of this neighbourhood will reflect on to the sea thus increasing its intensity.
Nutrition and Physical Activity Nutrition, physical activity and obesity are inter related.

Malta's demography is clear.

We are an overweight and obese society, more so in childhood.

(Victoria Farrugia Sant'Angelo, Victor Grech) Obesity has become a dominant public health problem and is associated with increased risks of heart disease, diabetes, stroke and musculoskeletal diseases.

Gzira is the traffic route to other destinations.


It is a stop over for many non-locals for a quick snack and certain areas are also visited for leisure.

Food stores, confectionaries, take aways and restaurants abound.

The proximity to unhealthy food associated with dietary behaviors relate to chronic disease outcomes, and food availability and food advertising influence the nutritional value of foods consumed.

Gzira is fast becoming such a place.


These environments contribute to Malta's overweight epidemic.

Green spaces specifically contribute to giving areas in which people can exercise.

Studies have shown that people living an indoor lifestyle, as in Gzira, have a higher risk of obesity and heart disease.

This access to green spaces helps give residents of urban areas the ability to hinder this possible negative effect.
Several studies have also shown that a short distance from homes to green recreational areas stimulates residents to walk, jog or bike more frequently in these areas.

Such activity is also a noted form of mental relaxation.

Afterallliving in a crowded locality is associated with increased social stress, since the surroundings becomes less controllable by the individual.
This increased anxiety and stress leads to lack of sleep and chronic fatigue, which if on going, compromises the immune system, and jeopardizes health.

A close look at Manoel Island's mega-project indicates that the only open public open space conceded, apart its shopping mall, will be located at the furthest point from the urban area of the locality and is to be limited to the 'glacis'.

These surround Fort Manoel on the landward side.


Its inclination will definitely reduce access to older and disabled people.

Access to green/ recreational areas is important aspect of land-use-mix in urban planning.

They provide a safe and healthy environment.

In this respect Gzira lacks physical activity facilities, walk ways and bike pathways in its streets.
This ODP has to be much more supportive than what is stated and must act as a prime mover to a basic right: the right to healthy living in Gzira.

HEALTH EQUITY Environmental health inequalities are a reality in Malta and this calls for environmental health justice.

Gzira is a prime example.

It is suffocating.

It is not ideal for young families to live in.

Its poor urban design and aspects of poor health already place a large burden on its community and national health services.
Unwise depletion of its urban environment by this project will be of a further detriment to the health and standard of living of the local population.

Decisions on urban planning and design need to take into account the potential long-term effects on health and health equity, alongside its impacts on the environment, economy and society.

This is Malta's major challenge.

We are a small archipelago and an over populated nation state.

This imposes huge limitations.


Moreover our economy is being addressed without strengthening resilience.

This ODP application is another stress test.

It is a project that is being imposed on a stressed community not of its doing.

We must forge a proceess that links health and urban design, not just for the project itself on its own standing, but as part of a holistic community, which makes Gzira.

Gzira needs freshness.

Gzira needs to be revitalized.

Gzira needs to regain its health and strength.


This project must: • ensure that its buildings and open spaces are an integral part of the whole town of Gzira.

• supports a healthy living for Gzira's residents.

• offers a healthy environment that sustains Gzira's residents and its last natural habitat.

• identify opportunities for increasing public accessibility.

• offer an inclusive place that favours opportunities for all citizens.
• offer a safe neighbourhood for residents, visitors and Gzira residents.

• offer a distinctive place that retains Gzira's residents strong identity, heritage and sense of belonging to Manoel Island.

• be a place that offers greater levels of active transport within it, by enhancing access and mobility, particularly for such groups as people on low incomes, older people, families and people with disabilities.

• reduce reliance on private transport.


• is a well-administered place that has a shared Gzira community vision and sense of direction.

It is therefore essential to identify all opportunities to improve the social, cultural and environmental character of Gzira in order to create a Healthy Gzira through this Manoel Island project.

At present this is a far cry, as the project is parasitic on an impoverished Gzira.
The Way forward: Gzira is a town of building canyons characterised by tall buildings in narrow traffic congested streets.

It is all the more important that public green open spaces are provided on Manoel Island to enable the population to de-stress and enjoy a healthy environment.

A park on Manoel Island would allow an extensive wooded area, first class heritage attractions, walk ways, swimming, boating and cycling.
Given its proximity to the densely populated areas of Sliema, Msida, Gzira and beyond, the park would be easily accessible on foot and will have an added value to the project.

Small boat ferries could also be organised giving the park a different approach from Valletta and Pieta.

CONCLUSIVE REMARKS It is people who make places.

The aim of HIA on Gzira is to enrich the processes of policy and planning on Manoel Island's ODP application.

The applicants have an obligation.


They have to integrate their project as one that belongs to Gzira and its residents.

This report has exposed the prevailing health hazards and highlighted the relevant influences on the habitat of Gzira.

It is now the responsibility of this Planning Board to process these concerns so as to reduce or mitigate further harmful effects with innovative solutions and trade-offs on behalf of urban healthy and wellbeing.
This Planning Board has a societal responsibility to protect the health of the resident population.
DATA SOURCES The report draws content from the following data sources The State of Environment Report 2028 https: //par lam en t.mtfm edia/ 9 7 648 /state-of-the environment-report-2018.pdf Strengthening resilience: a priority shared by Health 2020 and the Sustainable Development Goals (2 0 17) Boosting implementation of Health 2020 and the 2030 Agenda: the WHO Small Countries Initiative (2017) WHO European Childhood Obesity Surveillance Initiative: Implementation of round 1 (2007 /2008) and round 2 (2009/2010) (2014) Malta HiT (2017) Malta country profile on nutrition, physical activity and obesity (2013) Environmental health inequalities in Malta.
Assessment Report (2013) Impact of School Inborn Air Quality on Childhood's Respiratory Health in Maltese Primary Schools, Peter Fsadni https:ffaqicn.orgfmapfmalta/ Comparison of body mass index of a national cohort of Maltese children over a 3- year interval Victoria Farrugia Sant' Angelo, Victor Grech Body mass index estimation in a school-entry aged cohort in Malta VICTOR GRECH & VICTORIA FARRUGIA SANT'ANGELO The Malta Childhood National Body Mass Index Study- a population study.
Victor Grech Changes in Geographic Distribution of Wheezing Children in Malta between 1994 and 2002, Peter Fsadni http://www.euro.who.intfenfhealth- to pi cs /disease-p reve n ti o nfn u tri ti o nf country work/malta I https:ffwww.health.govt.nzfsystemjfilesfdocum entsjpublicationsfhia-urban-design-v2.pdf https:ffwwwl.health.gov.aujinternetfmainfpubl is hi ng.
nsf/Content/ A12B57E41EC9F326CA257BF0001F9E7Dj$File/ health -effects-Environmental-Noise-2 018. pdf Missing the Dark: Health Effects of Light Pollution https:llwww.ncbi.nlm.nih.gov lpmclarticlesiPMC 2627884/ l New ones https:llbay.com.mtlair-pollution-kills-570- p eo ple-a-year-in-mal tal It was a study from: h ttps: II a cad emi c.oup.coml eurh ear tj I article I 40 I .
20/1590/5372326 ~ https:llwww.mpg.del12823232lpolluted-air sh o rte ns-the-lifespan-o f- europeans-by-about two-years Ryan Vella's email Summary Urban planning and urban health cannot develop in separate tracks.

The physiognomy of Gzira is a prime example where urbanization has already taken the wrong path.

High traffic neighborhoods and a densely populated locality makes Gzira one of the worst human habitats in Malta.

Air, light, and noise pollution and traffic accidents are health hazards .
Ambient air pollutants characterise documented indoor air pollutants, which include nitrogen dioxide(N02), sulphur dioxide(S02), ozone (03) and carbon monoxide(CO), volatile and semi-volatile organic compounds, particulate matter(PM) and microorganisms.

As a consequence the residents of Gzira have increased morbidity and mortality when compared to other localities (a health inequality).

The health and wellbeing of a community is shaped by the environment within which people live.
This ODP application is a stress test, imposed on already stressed community.

The right to a healthy living calls for environmental justice.

This HIA forges the links health and urban design must have, not just for the project on its own standing, but as part of a holistic community, that makes Gzira.