Investment in Environment and Health

development policies could achieve health gain without economic growth. Improve-ments in water supplies, sanitation, food hy-giene and housing, and controls on air and water pollution are the most likely environ-mental investments to yield substantial health gain [13]. Judicious investment be-comes even more important in countries ex-periencing economic recession and in-flation. The questions that need to be ad-dressed include: the costs of improvements in health through environmental interven-tion, the time scales over which health gains can be realized, and whether these invest-ments are more cost-effective than others that could be made in sectors such as edu-cation and health care. It must be recognized that the main causes of premature mortality (see Chapters 4 and 18) are more likely to be attributable to lifestyle factors, particularly smoking, than to environmental agents.

Damage to the environment in the CCEE and NIS and its impact on health can be clearly seen in the level of emissions from the use of fossil fuels in production pro-cesses. Most factories in these countries use production systems that are obsolete, energy intensive and highly polluting in comparison with those in western countries. Industrial energy intensity is five times higher in Po-land, for example, than in the United States;

similar differences are found between Ger-many and Hungary [14–16]. The use of fossil fuel and the intensity of emissions are in-versely related to price [14] and adverse health effects are directly related to the re-sulting air pollution [16–18].

One flaw in using GDP to assess the econ-omic capacity of a country is that the stan-dard measure of GDP ignores the depletion and degradation of natural resources and their effects on health. Indeed, in so far as environmental damage creates treatable ill-ness and a cost to the health services, that cost creates employment and paradoxically appears as a positive contribution to GDP.

This is clearly misleading. Many countries, however, are adjusting their measure of GDP to take account of adverse environmental ef-fects and the depletion of natural resources.

Investment in Environment and Health 79

Businesses are attempting similar develop-ments in environmental accounting, and major industries are producing accounts that show more clearly to shareholders and the public the damage that their activities do to the environment and the extent of invest-ments to counteract these problems [2,19–

21]. These new forms of environmental ac-counting give a more complete picture of real change in national and corporate wealth and its relationship to environmental status in the community. Further developments in this accounting process should consider ad-verse effects on health.

Fig 3.2: Health and wealth: the correlation between real GDP per head (purchasing power parities) and life expectancy in the WHO European Region, 1990

In its strategy for health for all [22] WHO named decent housing, safe food, water and sanitation, adequate income and employ-ment as prerequisites for health, and these factors were part of the McKeown hypoth-esis of health development [23]. They also offer some explanation for differences be-tween countries in life expectancy. Further work is required in the Region to determine the exact impact of these factors and their importance in comparison with, for example, environmental pollution or individual life-styles.

While the environmental sector is import-ant, it competes with health care for invest-ments to improve health in the Region. A key issue in health care in the Region in gen-eral, and in the CCEE and NIS in particular, is the extent to which greater efficiency and perhaps greater investment in health care could reduce avoidable disease and mortality [24].

Avoidable mortality generally attributable to inadequate health care includes deaths from tuberculosis, cancer of the cervix, dia-betes, chronic rheumatic heart disease, cer-tain other types of circulatory disease and appendicitis; deaths principally related to en-vironmental conditions and lifestyle are ex-cluded. Rates of avoidable mortality are sub-stantial, but are declining in most western countries of the Region while remaining con-stant or increasing in certain of the CCEE and NIS [24]. Some of the CCEE and NIS have rates of avoidable mortality, in both males and females, 2–4 times greater than those in most western countries [24].

While political pressure is increasing to raise the level of national and international investment in environmental improvements with the aim of improving health, these in-vestments may not be high on the list of the

“best buys” for health [13].

Environmental improvement can lead to improved health by, for example, eliminating or reducing specific threats to health and creating the conditions that promote heal-thier lifestyles and better living conditions. It has been estimated that an extra investment of 2–3 % of GDP globally is necessary by the

end of the decade to stabilize soil conditions, protect forests, improve air quality, and pro-vide universal access to sanitation and clean water [2].

Further environmental improvements would require extra investment. Some pol-icies can, however, promote economic growth, alleviate poverty and create direct environmental improvements. For example, the removal of subsidies that at present en-courage the excessive use of fossil fuels and pesticides and the reduction of forests would promote greater efficiency in the use of re-sources, thus contributing both to economic growth and to environmental improvement [2]. Clarifying property rights on land, forests and fisheries would encourage rein-vestment and the removal of past pollution [14].Accelerating the provision of basic ser-vices such as sanitation, clean water, edu-cation and housing throughout the European Region would also contribute to economic growth and human welfare by unlocking further human capital, and directly and indi-rectly improve health [23].

Three types of better investment in envi-ronmental improvement can lead to health benefits. The first comprises policies, such as energy price reform, that are both econ-omically efficient and environmentally beneficial. Once provision has been made to secure the welfare of the poorest, whose sur-vival depends on heating and power, such policies can lead to net health gain from re-duced pollution. Second, regulatory policies and taxes can be used to internalize the costs of environmental damage; these either require polluters to bear the costs of reduc-ing emissions or to pay a charge that reflects the damage done by the pollution. Third, public investment in or the reduction of sub-sidies for public utilities (especially gas) in particular, but also for some other publicly owned enterprises, can be used to reduce emissions.

Since 1987, the EU has committed about 5 billion^a ECU to environmental improve-ment [3] but current investimprove-ment in countries

a 1 billion = 10⁹.

Issues for the CCEE and NIS 81 varies widely between the key areas of

con-cern. For example, while 22 % of investment in the EU is on reducing air pollution, the percentages for Portugal and Spain are only 2 % and 1 %, respectively. Portugal devotes only 14 % of its declared environmental in-vestment to improving waste disposal, in contrast to an overall figure for the EU of 29 %. Portugal allocates three quarters of its investment in environmental improvements to water, while Spain devotes less than half that proportion to the purpose [25]. This pattern of expenditure needs further review, because investment in environmental im-provement needs to be carefully targeted ac-cording to national priorities to produce the greatest health benefits. Reports of returns on investment should make transparent the nature and volume of the benefits to human health and other goals.

The level of investment in environmental im-provements in Europe seems low by com-parison with the likely benefits; its growth is poor and its targeting inexplicable [25].

What factors explain this?

In the past, both market-led and centrally planned economies inadequately protected health from the adverse environmental ef-fects of economic development [26]. Some control proved possible in improving water supplies, but the record on air and soil pollu-tion is indifferent. On average, the control of concentrations of particulate matter, seen as smoke from chimneys and other sources, has been better in richer than in poorer coun-tries [2]. The large variation in urban pollu-tion control in countries of similar income level, however, suggests that much can be done to improve the efficiency of control through better management and education, without new technology and building on the example of the best practice in each country.

Industrial growth and economic develop-ment do not necessarily mean more