of a low-carbon economy and the health co-benefits of environmental policies are being considered in the context of Rio +20 – the united nations Conference on Sustainable Development. Countries have begun to develop policies that benefit both the health of the planet and the health of people, and they recognize that collaboration between sectors is crucial to protect human health from the risks of a hazardous or contaminated environment.
burden of chronic diseases in modern societies is an ecological public health approach recognizing complex interactions between biological, behavioural, environmental and social factors and pursuing public health solutions that are coordinated with the pursuit of planetary economic and societal sustainability (250,251).
Socioeconomic inequities and the current global economic downturn hamper progress in reducing environment and health risks. In all countries, irrespective of national income, people with a low income are much more at risk from unhealthy environments than those with a higher income. Social determinants play a significant role in the levels of exposure to environmental factors and the severity of effects on the health of individuals and populations.
For example, high or growing poverty levels weaken the protective functions of the water supply and sanitation sector within national health systems.
People with a low income tend to live in less sanitary conditions, in less safe neighbourhoods, closer to sources of industrial pollution and other sources of chemical and other types of contamination and in low-quality housing, and they have less access to spaces promoting healthy living (249).
Water quality is under constant pressure, and safeguarding it is important for the drinking-water supply, food production and recreational water use. In the Eu, the legal requirements are based on the WHO guidelines for drinking-water quality, and frequent non-compliance is observed for enterococci, arsenic, lead, nickel, nitrate and other pollutants; in the eastern part of the European Region, the level of non-compliance is higher and more pathogens are present in the drinking-water supply systems. Additional pressure is expected from climate change, population growth, industrial needs and water abstraction by the domestic sector: total water abstraction is expected to decline by more than 10% between 2000 and 2030 in the Eu and create water stress in central and southern Europe and central Asia (252).
Foodborne diseases are a growing public health problem, as the amount of food prepared outside the home has increased steeply in recent years.
Ensuring safety throughout the increasingly complex food chain requires collaboration between the health sector, agriculture, food transport, food service establishments and the food industry. Food safety and security depend strongly on the availability of safe water, land-use policies and the availability of technological advances for improving food production, storage, transport and preparation.
global environmental changes, such as ozone depletion, climate change, biodiversity loss, the increasing numbers of environment and weather emergencies, and the rapid introduction of new materials and technologies can introduce new health problems, amplify existing ones and highlight the weaknesses of current health systems. For example, in the European Region, some of the effects of climate change are already being felt: the 70 000 deaths in the 2003 heat-wave provided a “wake-up call” as to what could happen if no action is taken. Even greater health risks from climate change are foreseen for the future: more heat-waves, droughts, floods and fires; rising sea levels, with consequences for coastal areas and settlements; permafrost melting in the north, with risks to infrastructure and viability; and worsening of the classic environmental and social determinants of health (such as air quality, water and food quality and quantity). Changes in the geographical distribution of infectious diseases, with possible localized outbreaks of new or re-emerging infectious diseases (such as dengue), are also anticipated (253). many effects of climate change can be felt far beyond the locations in which they originally occur. They can also create conflicts and competition for resources, as well as migration. The estimated costs of economic damage are huge and range
between 5% and 10% of gDP (254).
Although environment and health interventions involve a wide range of actors, the various types of environmental exposure (such as through air, water, soil, food, noise and ionizing and non-ionizing radiation) should be seen as integrated determinants of health and well-being across the life-course and settings of living. Sectors such as transport, water management, sanitation, energy production and agriculture play a more significant role in influencing health than the health sector alone, and intersectoral policies work on all levels, from the local to the international. The health sector has a distinctive role of promoting public health interventions by other sectors, identifying the risks to and determinants of health, and monitoring and evaluating the effects of policies and interventions.
The countries in the European Region launched the European environment and health process 20 years ago. This process is an example of a unique governance mechanism, operating through a series of ministerial conferences, that involves ministries responsible for health and the environment on an equal footing, amplifies the links and synergy with a number of multilateral environmental agreements and enhances the partnership with other intergovernmental bodies, such as the united nations Economic Commission for Europe, the united nations Environment Programme and the European Commission, as well as with civil society organizations (255).
Implementation of the Commitment to Act adopted by the Fifth ministerial Conference on Environment and Health, held in Parma, Italy in 2010, will be essential to better link health and sustainable development (256). In particular, the Parma Declaration set out the following environment and health priority goals, with time-bound targets to be achieved by 2020 by European member States:
• ensuring public health by improving access to safe water and sanitation;
• addressing obesity and injuries through safe environments, physical activity and healthy diet;
• preventing disease through improved outdoor and indoor air quality; and
• preventing disease arising from the chemical, biological and physical environment.
In addition, the Commitment to Act calls for:
• integrating health issues in all climate change mitigation and adaptation measures, policies and strategies;
• strengthening health, social welfare and environmental systems and services to improve their response to the effects of climate change in a timely manner;
• developing early warning, surveillance and preparedness systems for extreme weather events and disease outbreaks;
• developing educational and public awareness programmes;
• increasing the health sector’s contribution to reducing greenhouse-gas emissions; and
• encouraging research and development.
The core work of WHO, especially on strengthening national health sectors to improve national surveillance, alert and response systems, remains essential in the fight against water- and food-related diseases, as does its work on vaccine-preventable and neglected diseases. Important health gains could be
obtained by more closely adhering to the WHO recommendations on vaccine-preventable diseases such as viral hepatitis A.
Health impact assessment of the environmental determinants of health and of policies across sectors is a core function of the health sector: identifying the risks, understanding how they are related to human health and developing effective and efficient measures to address them. Health impact assessment has been essential for developing and implementing environmental standards and reducing or eliminating environmental risks and exposure.
As part of the primary prevention of diseases, efforts to improve urban planning, to enable increased physical activity and to enhance the mobility of ageing populations or people with disabilities lead to better health and well-being. Safer workplaces, public places and improved housing standards reduce the number of injuries and people’s exposure to environment and health risks from heat and cold and to chemicals and noise. Comprehensive systems approaches to road traffic, which improve the safety of the road environment, vehicles and drivers’ behaviour by addressing the leading risk factors for road traffic injuries, such as speed, drink-driving and inadequate use of protective devices, significantly improve road safety for drivers and for pedestrians, greatly reducing the numbers of deaths and injuries associated with transport. Fiscal measures, such as pricing water and sanitation services, taxing emissions of pollutants (including greenhouse gases) and providing incentives to reorient consumption patterns, promote cleaner technologies and more rational use of natural resources and conserve biodiversity. These are needed not only to ensure better health for existing populations but also to protect future generations.
In recent decades, a combination of voluntary action and of legally binding multilateral agreements and conventions has proven to be an effective mechanism for steering policy action to address environmental health challenges. For example, the Protocol on Water and Health to the 1992 Convention on the Protection and use of Transboundary Watercourses and International Lakes has required countries in the European Region to set targets and report progress on provision of access to water and sanitation, reduction of water-related diseases and protection of aquatic resources (257).
The Barcelona Convention for the Protection of the marine Environment and the Coastal Region of the mediterranean has had major effects in developing health-protecting measures by calling for the safe treatment of wastewater and its reuse as irrigation water (designed as a measure to adapt to climate change).
Other important examples of collaboration between WHO and other united nations agencies on the implementation of multilateral environmental agreements include the contribution of the WHO air quality guidelines to implementation of the Convention on Long-Range Transboundary Air Pollution, and the collaboration between WHO and the united nations Economic Commission for Europe in implementing the Transport, Health and Environment Pan-European Programme (THE PEP), a unique platform that brings together ministries responsible for transport, environment and health to achieve healthy and sustainable transport patterns. The WHO Regional Office for Europe also contributes to global conventions, such as by analysing health effects and promoting health in the Rio Conventions (in particular those on climate change and biodiversity).
The Regional Office has an important advisory and supportive role to play
9 Halving, by 2015, the proportion of the population without sustainable access to safe drinking-water and basic sanitation.
in cooperation with other agencies of the united nations system, such as unICEF in the Joint monitoring Programme for Water Supply and Sanitation to monitor progress towards millennium Development goal 7;9 un-Water (an interagency mechanism) in the global Annual Assessment on Sanitation and Drinking-water, and the united nations Economic Commission for Europe in ensuring equity in access to safe water and improved sanitation.
A well-functioning system of environment and health governance at the level of the WHO European Region plays a major role in bringing together stakeholders from across the sectors and stimulating coordinated action to address the environmental burden of disease. The role of civil society groups is likely to be a particularly important factor in environment and health governance in the future. In many places, political concern for environment and health is a belated reaction to pressures from civil society.
Just as the quality of the environment and the nature of development are major determinants of health, so is health an important stimulus to other aspects of development. Human health depends on society’s capacity to manage the interaction between human activities and the environment in ways that safeguard and promote health but do not threaten the integrity of the natural systems on which the environment depends.
The goal of sustainable development is to meet the needs of the present without compromising the ability of future generations to meet their own needs. The concept of sustainable development encompasses more than sustainability. Sustainable development implies a paradigm shift from a model of development based on inequity and exploitation of resources to one that requires new forms of responsibility, solidarity and accountability, not only at national level but also globally and across generations.
The links between better health, the economy and the environmental sustainability are well established: people who are healthy are better able to learn, to earn and to contribute positively to the societies in which they live.
Conversely, a healthy environment is a prerequisite for good health (258).
The global plan of action agreed at the united nations Conference on Environment and Development in 1992 (259) and the Rio Declaration on Environment and Development (260) are still valid. However, although the WHO European Region has witnessed strong economic growth and significant progress in health, including progress towards attaining several of the millennium Development goals, these positive trends have been accompanied by increasing disparities, health inequity, environmental deterioration, climate change and recurrent economic, financial, energy and food crises (261). The need for a new, more coherent approach to environmental policy is also illustrated by the fact that, 20 years after the first Rio summit, the key decisions in many countries that affect the environment – policies on development, urban planning, transport, energy and agriculture choices and housing development – create rather than reduce air pollution, noise, chemical pollution and traffic injuries.
Several national and local case studies have illustrated the fact that the policies of various sectors and settings can also promote health benefits. many of them use green-economy approaches. The following examples link decisions in one area (such as transport or urban planning) with better health and well-being.
The united nations (262) has argued that systemic changes are barely possible without real action to address levels of consumerism and resource use.