More than 1.7 million annual deaths (18% of all deaths) are attributable to environmental factors in the European Region. The environment accounts for an estimated one third of the total burden of disease for children and adolescents aged 0–19. Well-designed environmental health interventions could reduce total mortality in the Region by almost 20% (40).
The burden of disease due to known environmental factors is unevenly distributed between countries, varying up to fourfold across the Region (Table 2.15). This is due to multiple factors, including differences in exposure to a combination of risk factors such as unsafe
drinking-Subregion and country DALYs Estimated deaths
Per capita (thousands) % Number %
Eur-A
Czech Republic 21.4 15 17 606 16
Denmark 19.1 14 9 235 16
United Kingdom 18.1 14 101 335 17
Eur-B
Albania 29.9 19 4 425 27
Armenia 26.3 16 4 712 18
Azerbaijan 35.7 19 12 927 28
Bosnia and Herzegovina 25.6 16 6 172 20
Bulgaria 28.6 16 18 469 16
Georgia 27.1 16 10 874 28
Kyrgyzstan 46.2 21 9 706 28
Poland 25.2 17 66 113 18
Romania 30.8 17 46 928 17
Serbia and Montenegro 26.8 15 21 023 19
Slovakia 25.1 16 9 315 18
Tajikistan 47.5 21 12 021 45
The former Yugoslav Republic of Macedonia 23.7 15 3 137 17
Turkey 30.4 19 86 712 20
Republic of Moldova 34.5 17 8 952 21
Russian Federation 53.7 20 493 116 21
Ukraine 43.2 19 155 230 21
Table 2.15. Estimated deaths and DALYs lost due to environmental factors, WHO European Region, 2002
Source: Preventable environmental impact on mortality and morbidity in countries of the WHO European Region (2007) (41).
water, poor sanitation and hygiene and air pollution. In turn, countries’ capacity and political determination to adopt effective interventions and legislation strongly influences this exposure. (This section introduces the country groups Eur-A, -B and -C.3)
Known risk factors
Much of the burden attributable to the environment is due to established risk factors whose relationships to health are now well understood and for which reliable evidence is available on the effectiveness of the policies and interventions used in response. Important ones for countries in the European Region include (Table 2.16): access to safe water and improved sanitation, exposure to air pollution, exposure to persistent organic pollutants, mercury and pesticides, occupational risks and injuries.
Access to safe water and improved sanitation
Lack of access to safe drinking-water is still a leading cause of death among children aged 0–14 years in the Region. About 13 000 annual deaths (5.3% of the total mortality among children: 0.2% in Eur-A, 7.5% in Eur-B and 2.4% in Eur-C) are attributable to diarrhoeal disease related to exposure to unsafe drinking-water (43). About 13 million people in Eur-B and 9 million in Eur-C do not have access to improved sources of water; 18 million in Eur-B and 32 million in Eur-C lack access to improved sanitation. Rural populations tend to have poorer access to safe drinking-water supply: 66% in Eur-B and 56% in Eur-C (Fig. 2.14) (44). The slow progress in achieving universal access to safe drinking-water and improved sanitation, especially in rural areas in the eastern part of the Region, jeopardizes the achievement in the Region of MDG 7 (ensuring environmental sustainability) and the fulfilment of a basic human right. Action is needed to ensure safe drinking-water from source to tap, to improve the management of water demand and to take full advantage of supportive policy instruments, such as the WHO/United Nations Economic Commission for Europe (UNECE) Protocol on Water and Health to the 1992 Convention on the Protection and Use of Transboundary Watercourses and International Lakes (45).
Exposure to air pollution
Outdoor and indoor air pollution is an important determinant of health, increasing mortality from cardiovascular and respiratory diseases and reducing life expectancy by about 8.6 months in EU countries. It reduces life expectancy by more than 13 months in the most polluted countries. In the past two decades, significant progress has been achieved in reducing the emissions of some air pollutants, such as sulfur, nitrogen oxides and lead. This is mostly due to improvements to industrial and energy production processes and increased energy efficiency and fuel quality. Nevertheless, nearly 90% of residents of urban areas are still exposed to air pollution concentrations exceeding WHO guideline levels (46). The average exposure by country varies by a factor of three in the Region. On average, the concentrations of the main air pollutants (particulate matter, ozone and nitrogen dioxide) and related risks to health did not change or increased slightly from 2000 to 2006.
3 Eur-A: 27 countries with very low child and adult mortality: Andorra, Austria, Belgium, Croatia, Cyprus, the Czech Republic, Den-mark, Finland, France, Germany, Greece, Iceland, Ireland, Israel, Italy, Luxembourg, Malta, Monaco, the Netherlands, Norway, Portugal, San Marino, Slovenia, Spain, Sweden, Switzerland and the United Kingdom.
Eur-B: 17 countries with low child and adult mortality: Albania, Armenia, Azerbaijan, Bosnia and Herzegovina, Bulgaria, Georgia, Kyr-gyzstan, Montenegro, Poland, Romania, Serbia, Slovakia, Tajikistan, the former Yugoslav Republic of Macedonia, Turkey, Turkmenistan and Uzbekistan.
Eur-C: 9 countries with low child but high adult mortality: Belarus, Estonia, Hungary, Kazakhstan, Latvia, Lithuania, Republic of Moldo-va, the Russian Federation and Ukraine.
Table 2.16. Deaths and DALYs lost attributable to environmental risk factors, WHO European Region, 2002
Country Population
(thousands) Water, sanitation and hygiene Indoor air pollution Outdoor air pollution
Population (%) with: Diarrhoea Population
Russian Federation 144 082 97 87 700 0.3 9 400 0.0 25 48 37 200 1.9
Ukraine 48 902 96 96 < 100 0.3 6 200 0.1 29 42 15 200 2.0
a Urban population weighted average for particulate matter less than 10 microns in diameter (PM10) (estimate or monitored when available).
b Percentage living in cities with populations > 100 000 or national capitals.
c In this case, years of life lost to premature mortality.
d Zero of estimation or method not sensitive enough.
e Not available.
Source: Deaths and DALYs attributable to three environmental risk factors [online database] (42).
Exposure to persistent organic pollutants, mercury and pesticides
The phasing out of lead in petrol, first in western Europe and later in central and eastern Europe, significantly reduced blood lead concentrations among children during the past two decades (47). Nevertheless, lead exposure is still considerably higher in the south-eastern part of the Region than the northern and western parts. As children have no known safe exposure level, the concentrations of lead in blood need to be further reduced. In many countries, the legislative basis of the air quality management system and air quality monitoring needs to be updated to better reflect the WHO air quality guidelines (46). Moreover, clearer guidance on indoor air quality is required. The WHO Regional Office for Europe is developing guidelines on indoor air quality.
A few countries have provided data on persistent organic pollutants in human milk. These data indicate that population exposure to certain persistent organic pollutants, such as dioxin, has declined in the past decade, although countries differ (48). New compounds have emerged: polybrominated and polyfluorinated compounds. Mercury and its compounds are highly toxic to humans, ecosystems and wildlife. Even relatively low doses can have serious neurotoxic effects on adults and children. In some countries in the Region, consuming contaminated fish or large amounts of uncontaminated fish results in hazardous intake of methylmercury. As this counteracts the otherwise beneficial health effect of fish consumption, reducing the concentration of mercury in fish should be a high priority. Reducing emissions to the atmosphere and avoiding soil contamination are means of achieving this aim.
Although most countries in the Region regulate pesticides, they can harm health and the environment, and careless use and overuse can exacerbate the effects. The use of obsolete
0 20 40 60 80 100
Azerbaijan Republic of Moldova Tajikistan Turkmenistan Kazakhstan Uzbekistan Romania Georgia Kyrgyzstan Ukraine Albania Latvia Lithuania Russian Federation Belarus Bosnia and Herzegovina Slovakia Croatia Hungary Bulgaria MKD Armenia Czech Republic Estonia Serbia Turkey Montenegro Ireland Poland Portugal Spain Andorra Austria Belgium Cyprus Denmark Finland France Germany Greece Iceland Israel Italy Luxembourg Malta Monaco Netherlands Norway Sweden Switzerland United Kingdom
Urban house connection Rural house connection
Population (%)
Fig. 2.14. Percentage of the population with access to an improved water supply, urban and rural areas, WHO European Region, 2006
Note. MKD is the International Organization for Standardization (ISO) abbreviation for the former Yugoslav Republic of Macedonia.
Source: Joint Monitoring Programme for Water Supply and Sanitation (44).
pesticides remains a problem in some of the countries in central and eastern Europe and the Caucasus. Some countries are addressing this problem, but others need to strengthen action.
Occupational risks
Hazardous exposure at the workplace is among the 10 most important risk factors affecting the burden of disease in Europe. Each year about 300 000 people die from occupational diseases and 27 000 from occupational injuries in the Region. Occupational diseases and injuries result in a loss of about 4% of GDP. The incidence and mortality rates vary significantly between countries, largely owing to differences in the reporting systems. Nevertheless, the absence of a clear overall decline in work-related injuries indicates that progress is not adequate. Action is needed to fully implement World Health Assembly resolution WHA60.26 (49), which highlights opportunities for combining health protection from occupational hazards with health promotion interventions at the workplace.
Injuries
Unsafe environmental conditions play a major role in determining injuries. For example, an estimated 25% of road traffic injuries in western Europe is attributable to environmental conditions, such as road infrastructure and the availability of pavements and facilities for cyclists and pedestrians (50). Injuries represent the third leading cause of death in the Region, with almost 800 000 lives lost annually; 66% of these deaths are preventable (51), and the costs are an estimated 2% of GDP. The political and economic transition in the Region has resulted in increased inequality in injuries. Differentials between countries are high and increasing (Fig. 2.15).
Fig. 2.15. External causes of death (injury and poisoning): SDRs per 100 000 population by country group, WHO European Region, 1980–2006
Source: European Health for All database (4).
Deaths per 100 000
Year
1980 1990 2000 2010
0 50 100 150 200
European Region EU
EU15 EU12
Eur-A CARK CIS
Eur-B+C
The ratios of mortality rates vary between low- and middle-income countries and high-income countries in the Region by individual injury cause, ranging from 16.9 for poisoning to 1.3 for falls. Within countries, the rates for road traffic deaths are 3.5 times higher among children of lower social class than those of higher social class; for poisoning, this ratio is 18. Through resolution EUR/RC55/R9, the WHO Regional Committee for Europe advocates reducing violence and unintentional injury by promoting an evidence-based and multisectoral public health approach (52).
Emerging concerns
In recent years, several other risk factors have emerged that are less well known but cause concern because of their likely impact, upward trends, uncertainty surrounding the extent and severity of their effects, or potential for long-term health effects. These include: climate change, waste-related exposure, foodborne disease and energy insecurity.
There is now strong consensus that the climate is changing. If current trends continue, rising temperature and sea levels and more frequent extreme weather events could increase mortality and morbidity and worsen the determinants of health. Potential health threats include shortages of food and water, loss of shelter and livelihoods, outbreaks of vector-borne disease and increasing inequality within and between countries (53). Some of these effects have already increased in Europe; for example, the 2003 heat-waves caused more than 70 000 excess deaths (54). Heat-related mortality is estimated to increase by 1–4% for each 1 oC rise in temperature, meaning that it could rise by 30 000 annual deaths by the 2030s and 50 000–110 000 annual deaths by the 2080s (55).
Climate change will be a main challenge for environmental health in the foreseeable future (56) and is a WHO priority (57). Issues include:
• temperature-sensitive infectious disease, such as foodborne infections, which could lead to an extra 20 000 annual cases by the 2030s and 25 000–40 000 annual cases by the 2080s (58);
• changes in infectious disease transmission by vectors such as mosquitoes and ticks, as a result of changes in their geographical ranges, seasons of activity and population sizes (53);
• heavy precipitation, linked to some outbreaks of waterborne diseases, from mobilizing pathogens or extensive water contamination from overflowing sewage pipes; and
• important effects on the concentrations and dispersion of air pollutants: for example, the United Kingdom could have about 800 additional annual ozone-related deaths by 2020 (59).
Despite the lack of unequivocal evidence on the health implications of current practices for waste management, there are concerns about the health effects of several options, including landfilling, incineration and disposal of health care and other hazardous waste. Given the growing generation of waste, policy-makers must increasingly choose the most appropriate policies for safely disposing of it. A review of European case studies on the health effects of landfills and incinerators reaffirmed the importance of the EU’s waste management hierarchy, favouring the minimization of waste generation, followed by the reuse of goods, value recovery through recycling and composting and, finally, incineration and landfilling, preferably with energy recovery (60). Further developing and applying economic assessment of waste management options and of participatory approaches for identifying health-friendly policy responses is a priority. Special attention should be paid to the illegal practices and toxic
waste dumping documented in the eastern part of the Region, which can have potentially serious health implications, and as already seen in the Campania region in Italy (61).
Foodborne disease constitutes a considerable public health burden and challenge throughout the Region. Due to insufficient reporting systems, the available data are not systematic and do not allow reliable comparisons. The incidence of foodborne diseases, however, is estimated to be many times higher in the eastern than in the western part of the Region (62).
Diseases of zoonotic origin are of particular concern. These include commonly reported diseases such as salmonellosis, campylobacteriosis and brucellosis. Botulism and zoonotic parasitic diseases (such as trichinellosis and echinococcosis) are reported in some parts of the Region. The food chain can be contaminated by various chemical hazards, such as dioxins, persistent organic pollutants and heavy metals. Although many of the traditional hazards remain, problems are also emerging as a result of changing risk factors, including:
• the centralization, industrialization and globalization of the food chain;
• changing consumer behaviour such as eating more outside the home and eating more raw food;
• changes in pathogens; and
• antimicrobial resistance, an increasing public health problem that is partly related to the use of antimicrobial agents in animals.
The second WHO European Action Plan for Food and Nutrition Policy (62), developed to support countries in implementing national plans, addresses the main public health challenges in nutrition and food safety and security.
Securing access to safe, clean, reliable and affordable sources of energy for households for heating and cooking is an important new concern. This has been prompted by a combination of increasing evidence of the health effects of indoor air pollution caused by solid fuel, several cold spells that were particularly dramatic in the CARK and crises in the international trade of natural gas. These highlight the need to protect the most vulnerable segments of society and to ensure a continuous supply of energy to the health care infrastructure, including during extreme weather events.
Evolving response to old and new challenges
Environmental health risks are increasingly complex and multifactorial. The traditional approach, based on risk assessment, has important limitations. As underlined by recent international discussion, much work is still required to close the gap between science and policy, to ensure that the achievements of research inform policy-making, even under conditions of high uncertainty (63). Many tools and institutional structures are needed, including adopting precautionary approaches. The WHO Regional Office for Europe has long promoted the precautionary principle as a tool for protecting health, the environment and the welfare of future generations.
In addition, WHO and other health agencies have expanded the scope of their work in environment and health and broadened the subject to include upstream determinants of health, such as development plans and policies. As part of their stewardship role in the health system, European governments – especially health ministries – are increasingly taking the health-in-all-policies approach, which considers the health implications of policies and decisions of various sectors such as transport, energy, industry, housing and tourism (64) (see the section on stewardship for healthy public policies in Part 3). Member States recognize the importance
of addressing environmental health risks at the national level through multisectoral policy action, using consultative processes such as environmental health performance reviews and capacity-building activities.
The environment and health process in the European Region, with its series of ministerial conferences on environment and health, the WHO/UNECE Protocol on Water and Health (45) and the Transport, Health and Environment Pan-European Programme (Box 2.1) are examples of processes that facilitate the direct engagement of sectors to better protect health.
The adoption of the Tallinn Charter (36) and the preparation of the Fifth Ministerial Conference on Environment and Health, to be held in Parma, Italy in 2010 (66) represent important milestones in achieving strong political consensus on and support for enhancing the stewardship role of health systems in addressing the environmental effects on health in the Region.