Sorge um die Zukunft Europas. Gesundheit und Umwelt in der Europäischen Region der WHO

(1)

(2)

Concern for Europe’s Tomorrow Health and the Environment in the WHO European Region

(3)

(4)

(5)

The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the Secretariat of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its fron- tiers or boundaries.

The views expressed in this publication are those of the contributors and do not necessarily represent the deci- sions or the stated policy of the World Health Organization.

The Federal Minister for the Environment, Nature Conversation and Nuclear Safety (Federal Republic of Ger- many) provided financial support for, and undertook the printing of, this publication.

Die Deutsche Bibliothek – CIP-Einheitsaufnahme

Concern for Europe’s tomorrow : health and the environment in the WHO European region / WHO European Centre for Environment and Health. [Publ. on behalf of the World Health Organization Regional Office for Europe]. – Stuttgart : Wiss.

Verl.-Ges., 1995

ISBN 3–8047–1406–4

NE: European Centre for Environment and Health

Published on behalf of the World Health Organization Regional Office for Europe by Wissenschaftliche Ver- lagsgesellschaft mbH

No part of this book may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, microfilming, recording, or otherwise, without written per- mission from the copyright holder.

Wissenschaftliche Verlagsgesellschaft mbH, Birkenwaldstraße 44, D-70191 Stuttgart, Germany.

Printed in Germany

(6)

5

Foreword

The remarkable political changes that have taken place within the European Region in the last five years have greatly enlarged the potential for international collaboration. The First European Conference on Environment and Health was held in Frankfurt in De- cember 1989, when these dramatic changes were at their height. Ministers from 29 countries, and the European Commission, approved a Charter that set out the principles, strategy and priorities for achieving an effective approach to the many areas in which environmental conditions may significantly affect human health.

The Charter reflected the ministers’ concern that the nature and extent of environmental health problems throughout the Re- gion had not been adequately assessed. The WHO European Centre for Environment and Health, which was established as a direct result of the Conference’s recommendations, was therefore given as its first major task the development of a comprehensive review of available data in such fields as water supply and sanitation, air and water pollution, radiation protection, food safety, occupational health, and housing and settlements. The project was entitled Concern for Europe’s Tomorrow, and the Scientific Ad- visory Board of the European Centre de- cided that the final report should be available as the scientific basis for deliberations at the Second European Conference on En- vironment and Health in Helsinki in June 1994.

The time available for preparation was extremely limited. The fact that a summary of the final report was available in time for the Second European Conference reflects great

credit on the many scientists (more than 270) and officially established national focal points in the Member States who have taken part in this major undertaking.

The report highlights a number of issues that demand urgent attention and has con- firmed the existence of major differences in environmental conditions and the health status of populations between the western countries of the Region and the countries of central and eastern Europe and the newly independent states of the former USSR.

None of the countries of our Region, however, has room for complacency. As one example, substantial areas of many Euro- pean cities provide a deteriorating environment for their citizens, owing to traffic noise, pollution and congestion, and social deprivation. Clearly, not all issues are of equal importance and it is hoped that the objective scientific nature of this report will help to allay unjustified public fears and to provide a more realistic perception of risk.

Above all, the report is intended to be of as- sistance in rational decision-making, so that real priorities may be identified and limited resources efficiently utilized.

The process of developing this report has demonstrated the shortcomings of the available data, in both coverage and consistency.

Nevertheless, the report is a major step forward. I am confident that the network of national focal points, which has now been firmly established, and the close collaboration between the WHO Regional Office for Europe and other international organizations, in particular the European Environ- ment Agency, provide excellent prospects for considerable improvements in the quantity

(7)

and quality of available information between now and the Third European Conference planned for 1999.

The present volume, which has been developed in very close cooperation with the Eu- rope’s Environment Task Force of the Euro- pean Commission, represents a major step forward in collaboration among all 50 countries of the WHO European Region. It is

hoped that it will be widely used, not only by government agencies but also by the very many nongovernmental organizations deal- ing with different aspects of the issues ad- dressed by Concern for Europe’s Tomorrow.

J.E. Asvall

WHO Regional Director for Europe

(8)

7

Part I

Background

1 Economic Sectors

The Setting 23

The Genesis of Concern for

Europe’s Tomorrow 24

The Development of Concern for

The Scope and Purpose of Concern

for Europe’s Tomorrow 27

Limitations and Constraints 28 Beyond Concern for Europe’s

Tomorrow 28

References 29

1.1 Introduction 33

1.2 The WHO European

Region 33

1.2.1 Basic features and

indicators 33

1.2.2 Development of economic

activities 36

1.2.3 The CCEE and NIS 36

1.3 An Outlook for the Future 39

1.3.1 Some trends 39

1.3.2 Some scenarios 40

1.4 Energy 40

1.4.1 Indicators and trends 41

1.5 Industry 48

1.6 Agriculture 51

1.7 Transport 54

1.8 Tourism 56

1.9 Urban Development 58

1.10 Conclusions 60

References 61

(9)

2 Environmental Health Management

3 Economics, the Environment and Health

4 State of Human Health

2.1 Introduction 63

2.2 Environmental Health

Services 64

2.3 Intersectorality 65

2.4 Involvement at the Local

and Regional Levels 66

2.5 Intervention and Control 69

2.6 Public Participation 70

Professionals 72

2.8 Conclusions 73

References 73

3.1 Introduction 75

3.1.1 Links 75

3.1.2 Environmental epidemiology and environmental

health economics 76

3.2 The Productive Economy

and the Environment 76 3.2.1 Response of industry to

environmental concerns 77 3.3 Investment in Environment

and Health 78

3.4 Failure of Economic

Systems 81

3.5 Issues for the CCEE

and NIS 81

3.6 Funding and Management of Environmental

Improvement 83

3.7 Economic Instruments 84

3.8 Information 85

3.9 Conclusions 87

3.9.1 Economic strategy 87

3.9.2 Information 88

References 88

4.1 Introduction 90

4.2 Demographic, Socioeco-

nomic and Lifestyle Data 91 4.2.1 Population size and

age structure 91

4.2.2 Population distribution 92 4.2.3 Socioeconomic factors 92 4.2.4 Lifestyle indicators 93 4.3 Availability and Interpreta-

tion of Health Data 93

4.4 Infant Mortality 96

4.5 Life Expectancy and Total

Mortality 98

4.5.1 Life expectancy 98

4.5.2 All causes of mortality 101 4.5.3 Spatial patterns at the

subnational level 102

4.6 Occurrence of Selected

Diseases 103

4.6.1 Structure of total mortality

by cause 103

4.6.2 Selected groups of

diseases 103

4.7 Inequalities in Health

Status 122

4.8 Conclusions 124

References 125

(10)

Table of Contents 9

Part II

Environmental Exposure

5 Air Pollution

6 Water Supply and Quality

5.1 Introduction 139

5.2 Potential Health Effects 140 5.2.1 Sulfur dioxide and suspend-

ed particulate matter 141

5.2.2 Lead 144

5.2.3 Nitrogen dioxide 144

5.2.4 Ozone 145

5.3 Ambient Air Pollution and

Exposure Assessment 146

5.3.1 Methodology 146

5.3.2 Sulfur dioxide 147

5.3.3 Suspended particulate

matter 151

5.3.4 Lead 153

5.3.5 Nitrogen dioxide 155

5.3.6 Ozone 157

5.4 Indoor Air Pollution 160 5.4.1 Pollutants and their

sources 160

5.4.2 Effects on health 161

5.4.3 Exposure in Europe 164 5.5 Global and Transboundary

Air Pollution 165

5.5.1 Climate change in the

European Region 166

5.5.2 Ozone depletion in the

European Region 167

5.5.3 Acid deposition in the

European Region 167

5.6 Trends 168

5.6.1 Ambient air 168

5.6.2 Indoor air 170

5.6.3 Problems in exposure and

health risk assessment 170 5.6.4 Global and transboundary

air pollution 171

5.7 Conclusions 171

References 172

6.1 Health Effects 176

6.1.1 Guidelines and standards

for drinking-water 177 6.1.2 Microbial contaminants 178 6.1.3 Chemical contaminants 179

6.2 Exposure 184

6.2.1 Exposure to microbial

contamination 184

6.2.2 Exposure to chemical

contamination 187

6.2.3 Water supply coverage and

shortages 191

6.3 Causes of Exposure to

Waterborne Hazards 194

6.3.1 Inadequate raw water quality

and quantity 195

6.3.2 Inadequate treatment and

distribution 196

6.4 Trends 196

6.4.1 Demands for surface water

and groundwater 196

6.4.2 Quality 197

6.4.3 Sources of pollution 198 6.4.4 Technical and infra-

structure needs 198

6.4.5 Management and control 199

6.5 Conclusions 199

References 201

(11)

7 Wastewater and Surface Water

8 Solid Waste

9 Contamination of Food and Drink

7.1 Health Effects 203

7.1.1 Direct contact with surface

water through bathing 204 7.1.2 Direct occupational contact

with wastewater 205

7.1.3 Aerosols 205

7.1.4 Smells 205

7.1.5 Wastewater irrigation 206

7.2 Exposure 207

7.2.1 Populations with inadequate sewage disposal or

wastewater treatment

facilities 207

7.2.2 Exposure through

recreational use 210

7.2.3 Production and consumption of raw foods irrigated with water of insufficient

quality 212

7.3 Causes of Pollution 214

7.3.1 Wastewater 214

7.3.2 Pollution from non-point

sources 215

7.4 Trends 216

7.4.1 Improvements in networks

and treatment 216

7.4.2 Reduction of pollution 217

7.4.3 Monitoring 218

7.4.4 Management 218

7.5 Conclusions 219

References 220

8.1.1 Definitions 222

8.2 Waste Production 223

8.2.1 Municipal waste 223

8.2.2 Industrial waste 225

8.2.3 Mining waste 226

8.2.4 Small-quantity hazardous

waste 227

8.2.5 Health care waste 227

8.3 Waste Management 227

8.3.1 Collection 227

8.3.2 Disposal 228

8.3.3 Recovery, recycling and

prevention 230

8.4 Contaminated Sites 230

8.5 Transfrontier Movement

of Waste 231

8.6 Waste Management and

Health Effects 232

8.6.1 Methodological problems 232 8.6.2 Sanitary landfills 232

8.6.3 Incineration 233

8.6.4 Application of sewage sludges and compost to

land 235

8.7 Occupational Exposure to

Waste Substances 235

8.8 Trends 237

8.9 Conclusions 237

References 238

9.2 Food Safety Regulations, Services and Information

Systems 242

9.2.1 Current situation 242

9.2.2 Food safety structure 242 9.3 Microbiological Con-

tamination 243

9.3.2 Control measures 247

(12)

Table of Contents 11

10 Multimedia Exposure to Selected Chemicals 9.3.3 Foodborne diseases due to

microorganisms 249

9.4 Chemical Contamination 253

9.4.2 Exposure to chemical

contaminants 258

9.4.3 Evaluation of food contamination factors as indicated

by national focal points 263 9.5 Radioactive Contamination 264 9.5.1 Natural radionuclides 264

9.5.2 Weapons fallout 265

9.5.3 Chernobyl 266

9.5.4 Radiation dose 268

9.5.5 Risk 268

9.6 Safety of Food Produced

by Biotechnology 268

9.6.1 Fermented foods 269

9.6.2 Genetic modification 269 9.6.3 Implications of

biotechnology 269

9.7 Data Quality and

Comparability 269

9.7.1 National differences in the collection of information

and data 270

9.7.2 Comparability of national

data on outbreaks 270

9.8 Conclusions 271

9.8.1 Food safety regulations and

information systems 271 9.8.2 Microbiological contamina-

tion of food and related

foodborne diseases 272 9.8.3 Chemical contamination of

food and drink 272

9.8.4 Radioactive contamination

of food 273

9.8.5 Biotechnologically pro-

duced foods and drinks 273

References 273

10.2 Arsenic 280

10.2.1 Toxic and carcinogenic

effects 280

10.2.2 Exposure 280

10.2.3 Tissue levels 281

10.2.4 Evaluation of observed exposure levels and possible

health effects 281

10.3 Cadmium 282

effects 282

10.3.2 Exposure 282

health effects 284

10.4 Lead 285

effects 285

10.4.2 Exposure 286

health effects 287

10.5 Mercury 288

effects 289

10.5.2 Exposure 290

health effects 291

10.6 Pesticides 292

effects 292

10.6.2 Exposure 295

health effects 298

10.7 Nitrate 298

effects 298

(13)

11 Nonionizing Radiation

12 Ionizing Radiation

10.7.2 Exposure 298

health effects 299

10.8 Benzene 299

effects 300

10.8.2 Exposure 300

health effects 301

10.9 Polynuclear Aromatic

Hydrocarbons 301

effects 301

10.9.2 Exposure 301

health effects 302

10.10 Polychlorinated Biphenyls 303 10.10.1 Toxic and carcinogenic

effects 303

10.10.2 Exposure 304

health effects 306

10.11 Polychlorinated Dibenzo- p-Dioxins and Dibenzo-

furans 307

effects 307

10.11.2 Exposure 308

health effects 309

10.12 Conclusions 310

References 311

11.2 Ultraviolet Radiation 316

11.2.1 Solar radiation 316

11.2.2 Artificial sources of

UV radiation 318

11.2.3 Biological effects 319 11.2.4 Effects on health 320 11.2.5 Effects on the ecosystem 323

11.2.6 Conclusions 323

11.3 Electric and Magnetic

Fields 324

11.3.1 Interaction mechanisms 325 11.3.2 Biological effects 326 11.3.3 Epidemiological studies 328 11.3.4 Exposure limits and

protective measures 329

References 331

12.1 Sources 334

12.2 Biological Effects 336

12.2.1 Nature and quality of

ionizing radiation 336 12.2.2 Effects on health 336 12.2.3 Assessment of risk 337 12.3 Control of Exposure 337 12.3.1 Converting exposure to

dose 337

12.3.2 Alpha emitters 337

12.3.3 Recommendations on

radiation protection 339 12.4 Priorities in Environmental

Exposure 339

12.4.1 Radiation accidents 339 12.4.2 Safety of nuclear power

plants 344

12.4.3 Weapons testing 345

(14)

13 Residential Noise

14 Housing and the Indoor and Urban Environments

15 Occupational Health 12.4.4 Disposal of radioactive

waste 345

12.4.5 Radon 347

12.4.6 Occupational exposure 349

References 351

13.1 What is Residential Noise? 353 13.2 Magnitude of Problems 354

13.3 Annoyance 356

13.3.1 Disturbance of sleep 357 13.3.2 Communication

disturbances 359

13.3.3 Stress and fatigue 360

13.4 Effects on Health 360

13.5 Economic and Other

Consequences 360

13.5.1 Depreciation 360

13.5.2 Complaints 361

13.6 Regulations 362

13.7.1 Land-use planning 364 13.7.2 Health studies on exposed

populations 364

13.7.3 Concern for the future 364

References 365

14.1.1 Interaction of housing, other conditions and

health status 367

14.1.2 Housing factors affecting

health 368

14.1.3 Current housing and health issues in the European

Region 368

14.1.4 European health for all

targets related to housing 369

14.1.5 Urbanization 370

14.1.6 Current problems in Euro-

pean urban development 370

14.1.7 Housing policies 372

14.2 Studying Housing and

Health 373

14.2.1 Sources of information:

housing 373

14.2.2 Sources of information:

housing-related health

status 374

14.2.3 Housing stock 375

14.2.4 Space 376

14.2.5 Hygiene 377

14.2.6 Indoor air quality 379

14.2.7 Indoor climate 381

14.2.8 Groups with special needs 382 14.2.9 Accidents in the home 384

14.3 Trends 387

14.3.1 Urbanization 387

14.3.2 Homelessness 387

14.3.3 Accidents 387

References 388

15.1 Current Trends in European

Working Life 390

15.2 Important Factors at Work and in the Work Environ-

ment 392

15.2.1 Mechanical risk factors 393 15.2.2 Workload and ergonomic

conditions 397

15.2.3 Physical factors 398

15.2.4 Chemical hazards 400

(15)

16 Accidents and Man-made Disasters

17 Environmental Health in the CCEE and NIS 15.2.5 Biological agents and

organic dusts 404

15.2.6 Occupational allergens 406 15.2.7 Hazards to reproductive

health 406

15.2.8 Occupational carcinogens 408 15.2.9 Psychological factors 409 15.2.10 New technologies 411 15.3 Public Health Impact of

Employment 412

15.3.1 Accidental injuries 412 15.3.2 Occupational diseases 412 15.3.3 Work and noncommuni-

cable disease 415

15.3.4 Work disability and mortal-

ity of working populations 416

References 419

16.2 Technological Accidents with Environmental Effects

on Health 425

16.2.1 Chemical accidents 425 16.2.2 Radiation accidents 431 16.2.3 Accidents affecting food

and drinking-water 433

16.3 Accidents Affecting

Individuals 436

16.3.1 Traffic accidents 436 16.3.2 Accidental poisoning 439

16.4 Trends 441

References 442

17.1.1 Data limitations 444

17.2 State of the Environment

and Health 445

17.2.1 Air pollution 445

17.2.2 Water supply and quality 452

17.2.3 Solid waste 459

17.2.4 Radiation 460

17.3 Discussion 462

References 463

(16)

Part III

Analysis, Discussion, Conclusions and Recommendations

18 Estimated Health Effects of Environmental Exposure and Role of Economic Sectors

19 Conclusions and Recommendations 18.1 Effects on Health of

Environmental Exposure 467 18.1.1 Situation in the European

Region 469

18.1.2 Global and transboundary

effects 490

18.1.3 Effects on health of non-

environmental factors 492

18.1.4 Discussion 493

18.2 Role of Economic Sectors 496

18.2.1 Agriculture 497

18.2.2 Energy 500

18.2.3 Industry 504

18.2.4 Transport 508

18.2.5 Tourism 512

References 516

19.2 Economic Sectors 519

Management 521

19.4 Economics, the Environ-

ment and Health 522

19.5 State of Human Health 522

19.6 The Database 522

19.7 Air Pollution 523

19.7.1 Ambient air 523

19.7.2 Indoor air 524

19.8 Water Supply and Quality 524 19.9 Wastewater and Surface

Water 525

19.10 Waste 526

19.11 Contamination of Food

and Drink 527

19.12 Exposure to Selected

Chemicals 528

19.13 Nonionizing Radiation 529

19.13.1 Ultraviolet radiation 529 19.13.2 Electromagnetic fields 529 19.14 Ionizing Radiation 530

19.15 Residential Noise 530

19.16 Housing and the Indoor and

Urban Environments 531 19.17 Occupational Health 532 19.18 Accidents and Man-made

Disasters 534

19.19 Environmental Exposure in

some of the CCEE and NIS 535

19.19.1 The NIS 535

19.19.2 The CCEE 535

19.20 Global and Transboundary

Issues 536

19.21 Estimated Effects on Health of Environmental

Exposure 536

19.22 Role of Economic Sectors

in Environmental Health 537

(17)

Acknowledgements

The European Centre for Environment and Health of the WHO Regional Office for Eu- rope prepared this volume through its divi- sions in Bilthoven and Rome, together with the coordination unit in Copenhagen. The assessment of the situation in the fields of health and the environment covering such a vast area as the WHO European Region would not have been possible without the active support and collective efforts of a great many contributing individuals and institu- tions. The Regional Office is grateful to all who participated in this effort, either as authors, as reviewers or in any other capac- ity. The extensive list of contributors is a measure of the size and complexity of the task.

The Organization is greatly indebted to all ministries of health and of the environment in the Region for their active support. The network of national focal points for Concern for Europe’s Tomorrow (CET), acting as

links between the national authorities and the Regional Office, provided invaluable help in data collection and evaluation. The Regional Office is especially grateful to the chairman and members of the Scientific Ad- visory Board of the European Centre for En- vironment and Health who, together with nu- merous individual reviewers, carried out a detailed scientific critique of the drafts and provided sound advice on their improvement. The close cooperation of other international bodies, especially the European En- vironment Agency Task Force of the Euro- pean Commission, is appreciated.

The Regional Office wishes to record its special gratitude to Dr Barbara MacGibbon, who undertook the very difficult task of overall compilation and scientific editing of the whole report. Without her invaluable contribution, publication of this book would not have been possible within the very limited time available.

National focal points for CET

Contributors

Q. Kodra (Albania) A. Hrair (Armenia) G. Liebel (Austria) Galina Kurganskaya

(Belarus)

R. de Boeck (Belgium) H. Mileva (Bulgaria) M. Gunaric (Croatia)

K. Markvart (Czech Republic)

H. Balling (Denmark) R. Silla (Estonia)

A. Nevalainen (Finland) Y. Coquin (France) H. Lange-Asschenfeldt

(Germany)

G. Kamizoulis (Greece) G. Dura (Hungary) T. Ibsen (Iceland) R. Ellard (Ireland) R. Halperin (Israel) G. A. Zapponi (Italy) A. Zirnis (Latvia) J. Ptashekas (Lithuania)

(18)

18 Acknowledgements

Other national contributors

J. Alexander (National Institute of Public Health, Oslo, Norway)

T. Anavi (Tel Aviv University, Tel Aviv, Is- rael)

E. Andronache (Institute of Hygiene and Public Health, Bucharest, Romania) S.L. Avaliani (Sisin Institute of Community

Hygiene, Moscow, Russian Federation) A. Avni (Ministry of Health, Jerusalem, Is-

rael)

W. Babisch (Institute for Water, Soil and Air Hygiene, Federal Health Office, Berlin, Federal Republic of Germany)

B. Bayar (Ministry of Health, Ankara, Tur- key)

R. Becher (National Institute of Public Health, Oslo, Norway)

G. Bechu (Ministry of Health, France) N.E. Billo (Federal Office of Public Health,

Bern, Switzerland)

K. Binysh (Department of Health, London, United Kingdom)

G. Biro (National Institute of Food Hygiene and Nutrition, Budapest, Hungary)

C.-E. Boström (National Environmental Pro- tection Board, Stockholm, Sweden)

G. Brunborg (National Institute of Public Health, Oslo, Norway)

J. Cachia (Department of Health, Valletta, Malta)

R. Cachia Zammit (Department of Environ- ment, Valletta, Malta)

J. Carmes (Ministry of Health, France) P. Caruna (Public Health Laboratory, Vallet-

ta, Malta)

F. Cicogna (Ministry of Health, Rome, Italy)

M. Csanady (National Institute of Public Health, Budapest, Hungary)

M. Dodic-Fikfak (University Institute for Medicine and Social Welfare, Ljubljana, Slovenia)

B. Drougge (National Environmental Protec- tion Board, Stockholm, Sweden)

B. Duigu (Ministry of Reconstruction and Settlement, Ankara, Turkey)

S. Dumitrache (Institute of Hygiene and Public Health, Bucharest, Romania) M. Eriksson (National Board of Health and

Welfare, Stockholm, Sweden)

N. Essiz (State Planning Organization, An- kara, Turkey)

L. Ewetz (Institute of Environmental Medi- cine, Stockholm, Sweden)

W. Fonahn (National Institute of Public Health, Oslo, Norway)

E. Fröhlich (Federal Office of Public Health, Bern, Switzerland)

M. Gauci (Industrial Hygiene Unit, Valletta, Malta)

S. Gelberg (Ministry of Environmental Quality, Jerusalem, Israel)

M. Gerber (Ministry of Environmental Quality, Jerusalem, Israel)

Y. Gil (Ministry of Environmental Quality, Jerusalem, Israel)

A. Goren (Tel Aviv University, Tel Aviv, Is- rael)

F. Gösbebek (Turkish Atomic Energy Insti- tute, Ankara, Turkey)

J. Gubernskiy (Sisin Institute of Community Hygiene, Moscow, Russian Federation) S. Güven (State Statistics Institute, Ankara,

Turkey) P. Huberty-Krau (Luxem-

bourg)

A. Amato-Gauci (Malta) R. Passeron (Monaco) E. Lebret (Netherlands) E. Dybing (Norway) J. K. Ludwicki (Poland)

L. Delgado (Portugal) M. Cucu (Romania) N.F. Izmerov (Russian

Federation) M. Synek (Slovakia)

M. Macarol-Hiti (Slovenia) A. Fresno Ruiz (Spain)

K. Victorin (Sweden) B. Marti (Switzerland) S. Yüksel (Turkey) A.M. Serdiuk (Ukraine) E. Smales (United King-

dom)

(19)

J.-E. Haugen (National Institute of Public Health, Oslo, Norway)

F. Hirka (National Institute of Public Health, Budapest, Hungary)

A. de Hollander (RIVM, Bilthoven, Nether- lands)

J. Hongslo (National Institute of Public Health, Oslo, Norway)

A. Horvath (National Institute of Hygiene, Budapest, Hungary)

M. Hristova (Institute of Radiobiology and Radioprotection, Sofia, Bulgaria)

H. Huitfeldt (National Institute of Public Health, Oslo, Norway)

J. Indulski (Institute of Occupational Medi- cine, Lodz, Poland)

H. Isnard (Ministry of Health, France) L. Ivanovska (Ministry of Health, Skopje,

The Former Yugoslav Republic of Mace- donia)

M. Izrael (Institute of Radiobiology and Radioprotection, Sofia, Bulgaria)

V. Kalivoda, Federal Environmental Agency, Vienna, Austria)

K. Karlowski (National Institute of Hygiene, Warsaw, Poland)

N. Kehlkovskiy-Sergeev (Institute of Indus- trial Hygiene and Occupational Diseases, Moscow, Russian Federation)

M. Kertész (National Institute of Hygiene, Budapest, Hungary)

S. Khotimchenko (Institute of Nutrition of the Russian Academy of Medical Sciences, Moscow, Russian Federation) B. Kihlström (National Institute of Public

Health, Oslo, Norway)

E. Kivisäkk (National Radiation Protection Institute, Stockholm, Sweden)

V. Knizhnikov (Ministry of Health, Moscow, Russian Federation)

M. Köhalmi (Ministry of Welfare, Budapest, Hungary)

J. Korytkowsky (Ministry of Environmental Protection, Warsaw, Poland)

Z. Koszarny (National Institute of Hygiene, Warsaw, Poland)

D.I. Krammer, Federal Environmental Agen- cy, Vienna, Austria)

N. Lazarus (Department of Health, London, United Kingdom)

L. Licari, (Department of Health,Valletta, Malta)

G. Lilleheil (National Institute of Public Health, Oslo, Norway)

T. Lindner (Federal Ministry of Health, Sport and Consumer Protection, Vienna, Austria)

D. Lupulescu (Institute of Hygiene and Pub- lic Health, Bucharest, Romania)

T. Majle (National Institute of Hygiene, War- saw, Poland)

R. Maynard (Department of Health, Lon- don, United Kingdom)

S. Maziarka (National Institute of Hygiene, Warsaw, Poland)

T. Meredith (Department of Health, Lon- don, United Kingdom)

V. Metodiev, National Centre of Hygiene and Medical Ecology, Sofia, Bulgaria) M. Micallef (Department of Health, Valletta,

Malta)

I. Miller (Institute of Hygiene and Epidemi- ology, Prague, Czech Republic)

C. Milu (Institute of Hygiene and Public Health, Bucharest, Romania)

B. Montaville (General Directorate for Health, Paris, France)

C. Morawa (International Office of the Fed- eral Environmental Agency, Berlin, Ger- many)

H.-G. Mücke (Institute for Water, Soil and Air Hygiene, Federal Health Office, Ber- lin, Germany)

E. Ne’eman (Tel Aviv University, Tel Aviv, Is- rael)

B. Nikiforov, National Centre for Hygiene and Medical Ecology, Sofia, Bulgaria) K. Ormerod (National Institute of Public

O. Petursson, Office of Environmental Pro- tection, Reykjavik, Iceland)

T. Popov (National Centre of Hygiene and Medical Ecology, Sofia, Bulgaria)

V. Radmilovic (Federal Secretariat for La- bour, Health, Veterans’ Affairs and Social Policy, Belgrade, Federal Republic of Yu- goslavia (Serbia and Montenegro))

T. Radunsky (Federal Environmental Agen- cy, Vienna, Austria)

(20)

20 Acknowledgements

J. Rakhmanin (Sisin Institute of Community Hygiene, Moscow, Russian Federation) F. Ribarova (National Centre of Hygiene

and Medical Ecology, Sofia, Bulgaria) D. Ricochon (Ministry of Health, France) D. Riechman (Ministry of Health, Jerusa-

lem, Israel)

E. Rocco (Ministry of Health, Rome, Italy) M. Rouge (Ministry of Health, France) P. Rudnai (National Institute of Hygiene, Bu-

dapest, Hungary)

R. Skinner (Department of Health, London, United Kingdom)

S. Slorach (National Food Administration, Uppsala, Sweden)

T.-A. Stenström (National Bacteriological Laboratory, Stockholm, Sweden)

J.R. Sveinsson (State Housing Board, Reykjavik, Iceland)

N. Rusakov (Sisin Institute of Community Hygiene, Moscow, Russian Federation) E. Rydén (National Board of Housing, Build-

ing and Planning, Karlskrona, Sweden) E. Sabir (Ministry of Labour and Social Se-

curity, Ankara, Turkey)

M. Sammut (University of Malta, G’Mangia, Malta)

V. Scheftel (Ministry of Health, Jerusalem, Israel)

R. Schembri (Public Health Laboratory, Val- letta, Malta)

E. Schneider (Zentrales Arbeitsinspektorat, Vienna, Austria)

T. Schossberger (Ministry of Health, Jerusa- lem, Israel)

C. Serrano Carcia (Institute of Hygiene at the Workplace, Madrid, Spain)

V. Shinev (Institute of Occupational Health, Moscow, Russian Federation)

A. Spassov (National Centre of Hygiene and Medical Ecology, Sofia, Bulgaria)

D.I. Stadler (Bundesministerium für Land- und Forstwirtschaft, Vienna, Austria) F. Störmer (National Institute of Public

M. Sulcova (National Institute of Hygiene and Epidemiology, Bratislava, Slovakia) L.B. Sztanyik (National Institute of Radiobi-

ology and Radiohygiene, Budapest, Hun- gary)

N. Tarkan (Middle East Technical Univer- sity, Ankara, Turkey)

M. Tchutchkova (National Centre of Hygiene and Medical Ecology, Sofia, Bulgaria) S. Tekeli (Ministry of Trade and Industry,

Ankara, Turkey)

G. Tezcan (Ministry of Energy and Natural Resources, Ankara, Turkey)

I. Thirouin (Ministry of Health, France) S. Thorarinsson (Administration of Occupa-

tional Safety and Health, Reykjavik, Ice- land)

I. Trettwer (Österreichisches Statistisches Zentralamt, Vienna, Austria)

B. Tichacek (National Institute of Public Health, Prague, Czech Republic)

E. Tacoronte (Ministry of Health and Con- sumer Affairs, Madrid, Spain)

M. Tat (Institute of Hygiene and Public Health, Bucharest, Romania)

H. Toksoy (Ministry of Agriculture and Vil- lage Affairs, Ankara, Turkey)

U. Torsmark (National Environmental Pro- tection Board, Solna, Sweden)

D. Tricard (Ministry of Health, France) R. Tulbure (Institute of Hygiene and Public

Health, Bucharest, Romania)

G. Ungvary (National Institute of Occupa- tional Heath, Budapest, Hungary)

L. Vella (Industrial Hygiene Unit, Valletta, Malta)

T. Ulgen (Ministry of Health, Ankara, Tur- key)

L. Ursu (Institute of Hygiene and Public Health, Bucharest, Romania)

A. Vassallo (Department of Health, Valletta, Malta)

A. Wadge (Department of Health, London, United Kingdom)

K. Wahlberg (National Board of Occupa- tional Safety and Health, Solna, Sweden) H. Walker (Department of Health, London,

United Kingdom)

M. Waring (Department of Health, London, United Kingdom)

S. Whitehead (Department of Health, Lon- don, United Kingdom)

R. Zechner (Federal Ministry of Health, Sport and Consumer Protection, Vienna, Austria).

(21)

Thematic contributors

U. Ackerman-Liebrich (University of Basle, Switzerland)

G. Andreottola (Istituto per l’Ambiente, Milan, Italy)

M.E. Apeldoorn (RIVM, Bilthoven, Nether- lands)

J.H. Bernhardt (Institute of Radiation Hy- giene, Neuherberg, Germany)

C. Corchia (University of Sassari, Italy) R.B. Cundall (Medical Research Council,

Chilton, United Kingdom)

H. Dovland (Institute for Air Research, Lil- leström, Sweden)

K. Gerigk (Robert von Ostertag Institute, Berlin, Germany)

R.J. Gilbert (Central Public Health Labora- tory, London, United Kingdom)

A. Henne (Medizinisches Institut für Um- welthygiene, Düsseldorf, Germany)

D. Hill (Environmental Resources Limited, London, United Kingdom)

G. Jukes (Institution of Environmental Health Officers, London, United King- dom)

E.D. Kroese (RIVM, Bilthoven, Nether- lands)

S. Lagorio (Istituto Superiore di Sanità, Rome, Italy)

F. Langeweg (RIVM, Bilthoven, Nether- lands)

I. MacArthur (Institution of Environmental Health Officers, London, United King- dom)

K. Martignoni (Institute of Radiation Hy- giene, Neuherberg, Germany)

R. Mnatsakanian (Moscow, Russian Feder- ation)

Eva Nielsen (National Food Agency, Sø- borg, Denmark)

R. Novick (Potomac, USA)

O. Juhl Pedersen (Technical University, Co- penhagen, Denmark)

P. Peterson (MARC, London, United King- dom)

J. Rantanen (Finnish Institute of Occupa- tional Health, Helsinki, Finland)

J. Roberts (Adhealth Ltd, United Kingdom) F. Sella (Apples, Switzerland)

R.M.C. Theelen (RIVM, Bilthoven, Nether- lands)

P. Teufel (Robert von Ostertag Institute, Ber- lin, Germany)

B.T. Williams (University of Sheffield, United Kingdom)

E. Wirth (Institute of Radiation Hygiene, Neuherberg, Germany)

M. Wohlen (Gothenburg, Sweden).

Scientific reviewers Scientific Advisory Board

Sir Donald Acheson (Chairman, London School of Hygiene, United Kingdom) A.M. Kellerer (Institut für Strahlenbiologie,

Germany)

M. Maroni (International Centre for Pesti- cide Safety, Italy)

G. Pershagen (National Institute of Environ- mental Medicine, Sweden)

J.K. Piotrowski (Institute of Environmental Research, Poland)

J. Rantanen (Institute of Occupational Health, Finland)

U. Schlottmann (Federal Ministry for the Environment, Nature Conservation and Nuclear Safety, Germany)

V. Silano (Ministry of Health, Italy)

J. Weicherding (General Directorate of Health, France)

T.B. Zeltner (Federal Office of Public Health, Switzerland)

B.C.J. Zoeteman (Ministry of Housing, Physical Planning and Environment, Ne- therlands).

(22)

22 Acknowledgements

Individual scientific reviewers

T. Hancock (Public Health Consultant, Kleinburg, Ontario, Canada)

P. Kulling (National Poison Information Centre, Stockholm, Sweden)

M.D. Lebowitz (University of Arizona, Tuc- son, USA)

D. Larré (Director, Industry and Environ- ment Office, UNEP, Paris, France)

J.L. Larsen (National Food Agency, Søborg, Denmark)

C.J. Macfarlane (Ontario International Cor- poration, Government of Ontario, Cana- da)

E. Morava (National Public Health and Medical Officer Service, Pécs, Hungary) G. Salomon (Gentofte Hospital, University

of Copenhagen, Denmark)

A. Parving (Department of Audiology, Bis- pebjerg Hospital, Denmark)

A. Pintér (National Institute of Hygiene, Bu- dapest, Hungary)

R. Visser (OECD, Paris, France)

G. Winneke (Medizinisches Institut für Um- welthygiene, Düsseldorf, Germany).

Project Group of theEurope’s environment report

J.-P. Ribaut (Council of Europe)

J. Benes, Jaroslav Mejzr (ex-Czechoslovakia) T. Moth Iversen (Denmark)

G. Hilf (Eurostat)

L. Hopkins, Z. Karpowicz, T. Rajamets (IUCN)

K. van Egmond, R.M. van Aalst, Ad Minder- houd (Netherlands)

C. Avérous, C. Chung, P. Schreyer (OECD) M. Leonor Gomes (Portugal)

A.M. Goudyma, D. Kolganov (Russian Fed- eration)

T. Litscher (Switzerland) J. Martin (United Kingdom) A. Kahnert (UNECE)

A. Diamantidis, B. Ivanov, S. Jaakola (UNEP)

I. Waddington, J. Zakonyi, M. Krzyzanow- ski, B. Lübkert-Alcamo (WHO)

P. Bourdeau (Head of DG XI, EEA-Task Force)

D. Stanners (DG XI, EEA-Task Force, Pro- ject Manager of the Europe’s environment report).

WHO Regional Office for Europe

(a) European Centre for Environment and Health

B. MacGibbon (Scientific Editor)

K. Baverstock, R. Bertollini, B. Fenger, K. van der Heijden, R. Kersauze, M. Krzyza- nowski, B. Lübkert-Alcamo, P. Marchandise, R. Merineau, P. Rushbrook, R. Stern,

S. Tarkowski, I. Vlachonikolis, I. Wadding- ton, P. Weigert, M. Younes, J. Zakonyi (Pro- ject Officer for the CET report).

(b) X. Bonnefoy, M.S. Burgher, P. Charlton, O. Espinoza, E. Grandjean, D. Kello, F. La Ferla, A. Nanda, A. Nossikov, R. Prokhors- kas, K. Runeberg, L. Saliba, M. Shabanah, M.J. Suess, F. Theakston.

WHO Headquarters E. Giroult, T. Kjellström.

(23)

Introduction

Many of the great advances in public health during the nineteenth and twentieth cen- turies resulted from the realization that un- satisfactory water supplies, sanitation, working conditions, housing, food and air quality were major contributors to disease and short lifespans. More recently, protection of the environment for its own sake and the main- tenance of biodiversity for future generations have become important political issues throughout the world. The relationship of human health and wellbeing to environmental influences is an important dimension of these issues.

The relationship between environmental factors and health is complex. Many diseases have multifactorial causes and the influence of lifestyles and social and economic factors may be difficult to separate from environmental exposures.

Over recent decades, much of the WHO European Region has experienced rapid economic growth, but the benefits of increased overall prosperity have not always been accompanied by adequate measures to

The Setting

safeguard the quality of the environment.

This has resulted in a wide range of direct threats to human health as well as potential indirect effects, including some that may occur in the future as a result of the unsus- tainable nature of much economic development.

The situation is far from uniform. Basic health statistics^a show a general improvement in levels of health within the European member countries of the Organisation for Economic Co-operation and Development (OECD) as assessed by infant and total mortality rates, life expectancy and the incidence of certain diseases. By contrast, no improvement and in some aspects a deterioration in health status has occurred in the countries of central and eastern Europe (CCEE)^b and the newly independent states (NIS) of the former USSR over the last two decades. In addition, considerable variations occur

a Health for all database of the WHO Regional Office for Europe.

b The CCEE comprise Albania, Bulgaria, the Czech Republic, Estonia, Hungary, Latvia, Lithuania, Poland, Romania, Slovakia and the countries emerging from the former Yugoslavia.

The Setting 23

The Genesis of Concern for

The Development of Concern for

The Scope and Purpose of Concern

for Europe’s Tomorrow 27

Limitations and Constraints 28 Beyond Concern for Europe’s

Tomorrow 28

References 29

(24)

24 Introduction

among different social groups within individual countries of the Region, the poor every- where suffering more ill-health than the better off. If appropriate and cost-effective action is to be taken to create a greater de- gree of equity in health throughout the Re- gion, a better understanding must be reached of the role of the environment in influencing health, compared with social and economic inequalities, lifestyles and the quality of health care systems.

The definition of environmental health given in the European Charter on Environ- ment and Health [1] should be borne in mind:

Environmental health ... includes both the direct pathological effects of chemicals, radiation and some biological agents, and the effects (often indirect) on health and wellbeing of the broad physical, psychological, social and aesthetic environment, which includes housing, urban development, land use and transport.

While public health policies are understand- ably mainly directed towards relieving society of disease and premature death, the environment should also be considered as a re- source for enhancing health and wellbeing.

People aspire to live in communities free of environmental hazards, with decent homes in which to raise their families, with oppor- tunities for employment, education and cul- ture, and with pleasant and harmonious sur- roundings that facilitate recreation and social contact and maintain a healthy and diverse ecosystem. Effective environmental protection, in its widest sense, provides a framework for many of these aspirations, as part of enlightened and sustainable socioeconomic development.

While these are desirable aims, already within the reach of many people in the Re- gion, the far more basic needs of many others must also be recognized and dealt with as a matter of high priority. Many millions of people in the Region still lack at least one of the essential prerequisites of environmental health: safe water, clean air, sanitation and shelter. A substantial number are without the first and most fundamental prerequisite for health, namely peace. Reha-

bilitation of public services essential for environmental health and resettlement of large numbers of refugees will be major international tasks when hostilities have ceased.

If countries are to improve the health of their people, they must know what environmental conditions prevail. Concern for Europe’s To- morrow was launched to assess the state of environmental health in the Region. To ex- plain fully how this project came about, we must go back a little in time.

In 1980, the Member States of the WHO European Region adopted a common Euro- pean strategy for attaining health for all [2].

This called for fundamental changes in ap- proaches to health development. It focused on four areas of concern: lifestyles and health, the risk factors affecting health and the environment, the reorientation of the health care system, and the mobilization of political, managerial and technological support to bring about these changes. In 1984, the Member States of the Region approved 38 regional targets encompassing these areas. Their adoption proved to be a decisive event that gave a strong impetus to the wide political acceptance and implementation of the European health for all strategy. In many countries, the concepts, principles and strat- egies have already become reflected in national, regional and local policies. They have also provided a solid basis for health development in the CCEE and NIS, which has been greatly affected by political change in the last five years. While retaining their basic structure, the original targets were updated in 1991 [3]. As in 1984, nine targets are di- rectly concerned with aspects of environmental health.

Target 11 – Accidents

By the year 2000, injury, disability and death

The Genesis of Concern for

Europe’s Tomorrow

(25)

arising from accidents should be reduced by at least 25 %.

Target 18 – Policy on environment and health By the year 2000, all Member States should have developed, and be implementing, policies on the environment and health that en- sure ecologically sustainable development, effective prevention and control of environmental health risks and equitable access to healthy environments.

Target 19 – Environmental health manage- ment

By the year 2000, there should be effective management systems and resources in all Member States for putting policies on environment and health into practice.

Target 20 – Water quality

By the year 2000, all people should have access to adequate supplies of safe drinking- water and the pollution of groundwater sources, rivers, lakes and seas should no longer pose a threat to health.

Target 21 – Air quality

By the year 2000, air quality in all countries should be improved to a point at which recognized air pollutants do not pose a threat to public health.

Target 22 – Food quality and safety

By the year 2000, health risks due to microorganisms or their toxins, to chemicals and to radioactivity in food should have been significantly reduced in all Member States.

Target 23 – Waste management and soil pol- lution

By the year 2000, public health risks caused by solid and hazardous wastes and soil pollution should be effectively controlled in all Member States.

Target 24 – Human ecology and settlements By the year 2000, cities, towns and rural communities throughout the Region should offer physical and social environments supportive to the health of their inhabitants.

Target 25 – Health of people at work

By the year 2000, the health of workers in all Member States should be improved by mak-

ing work environments more healthy, reduc- ing work-related disease and injury, and pro- moting the wellbeing of people at work.

The need to achieve a better understanding of the relationship between environmental factors and the health of individuals and communities, together with the clear need for the environment and health sectors at all levels of government to work closely together, was recognized by the first European Conference on Environment and Health, held in Frankfurt-am-Main, Federal Republic of Germany, in December 1989.

The Conference culminated in the adoption, by ministers of health and of the environment and other senior representatives from 29 European countries and by the Commission of the European Communities, of the European Charter on Environment and Health [1]. The Charter sets out a broad framework for action by all levels of government, by all sectors of society and at the international level.

Subsequently, the WHO Commission on Health and Environment was established and produced a report entitled Our planet, our health [4] in preparation for the United Nations Conference on Environment and Development in Rio de Janeiro in 1992. This report analysed, within the global perspective, the various ways in which the environment interacts with health in the context of socioeconomic development, and provided a series of broad recommendations for action at international, national and local levels.

The Rio Conference endorsed the so-called Agenda 21 [5], an action plan for the twenty- first century that sets a far-seeing course towards sustainable development. Its health component largely reflects the findings of the WHO Commission and acknowledges that, within the overall principle of sustain- ability, major changes in approach are required if health impairment due to environmental degradation is to be arrested and future adverse environmental impacts on health prevented.

In response to Agenda 21, a global strategy for health and the environment was en-

(26)

26 Introduction

dorsed by the World Health Assembly in May 1993 [6]. An environmental programme for Europe, including an Action Programme for Central and Eastern Europe [7], was approved by an intergovernmental conference on the European environment held in Lucerne, Switzerland, in April 1993.

This action programme for the CCEE ac- cepts that health impacts are an important part of the immense environmental problems facing these countries as they move towards parliamentary democracy and market economies, although in many areas concrete information on these health aspects is lack- ing.

Ministers at the First European Confer- ence on Environment and Health had already acknowledged the inadequacy of the existing database and recognized that its strengthening was a prerequisite for national decision-making and the setting of priorities.

As a direct consequence of the adoption of the European Charter, the WHO European Centre for Environment and Health was established as an integral part of the WHO Re- gional Office for Europe. Its priority man- date was collaboration with Member States on the development of an improved information system, covering all aspects of the relationships between environmental conditions and human health.

At the first European Conference on En- vironment and Health in 1989 [1] it was agreed that:

European Ministers of Health and the Environment should meet again within five years to evaluate national and international progress and to endorse specific action plans drawn up by WHO and other international organizations for eliminating the most significant environmental threats to health as rapidly as possible.

In preparation for this Second European Conference on Environment and Health,

The Development of Concern for Europe’s Tomorrow

which was held in Helsinki in June 1994, the WHO European Centre for Environment and Health was asked to assess all aspects of environmental health in the countries of the Region, based on available national data and other information: the project known as Concern for Europe’s Tomorrow.

Since this project was first planned in 1991, many political changes have taken place in the Region and the number of WHO Member States has increased from 31 to 50.

While it was impractical to collect suffi- ciently detailed data from the NIS, the former Czechoslovakia and the former Yu- goslavia for inclusion in the main text of the report, the special conditions that exist in these countries had to be reflected. A separate chapter in this report therefore summar- izes the main environmental health issues in these countries.

From the outset, it was essential to work in harmony with other international bodies involved in assessing environmental conditions in the European Region, in particular the Commission of the European Commu- nities (CEC). As a result of the United Nations Economic Commission for Europe (ECE) Ministerial Conference held at Do- bris Castle in the former Czechoslovakia in June 1991, the development of a pan-Euro- pean report on the state of the environment was begun. A close working relationship has been established between the CEC secretariat coordinating preparation of this report and the project office at the WHO Regional Office coordinating the development of this book. Further, joint use has been made of some of the data available for these two com- plementary projects.

The major sources of information have been individual countries, international organizations and internal WHO material.

Member States were invited to nominate national focal points; they came together at a planning meeting in October 1991 and agreed on the project’s general concept and main lines of development. From the outset it was accepted that, in view of the short time frame, only existing data should be utilized. It was hoped that the limitations that

(27)

became evident during the progress of the work would indicate priority needs and stimulate the long-term development of an effective information system after the completion of the project.

Small task forces were convened to develop questionnaires on the various sectoral issues. Countries completed the questionnaires through the newly established network of national focal points. The replies, along with data and information obtained from other sources, were thereafter analysed by the chapter managers within the WHO European Centre for Environment and Health. The process of development of the project, and this report, involved two subse- quent meetings of the national focal points, which greatly contributed to its successful completion.

The Scientific Advisory Board of the WHO European Centre for Environment and Health acted as an independent peer review body for the emerging document and reviewed progress in November 1992, Sep- tember 1993 and January 1994. Peer review of separate chapters was carried out by appropriate specialists.

The main aim of the project was to provide a balanced and objective overview of the prin- cipal environmental issues of present or potential concern for health in the WHO Euro- pean Region. Of course, not all issues are of equal significance and priority in terms of human health. While this book does not provide a detailed comparative risk assessment, it is meant to help achieve a better understanding of the more important environmental factors that affect the health of the overall population or of potentially vulner- able groups. It is hoped that the gap between perceived risk and actual risk can thereby be narrowed by improving public information

The Scope and Purpose of Con- cern for Europe’s Tomorrow

and facilitating informed debate. This will have the twofold result that, on the one hand, people’s undue worries can be allayed and limited resources devoted to the most important tasks and, on the other, authorities and individuals can be persuaded to take action to prevent risks that they do not now take seriously enough.

It is axiomatic that prevention is better than cure. In terms of environmental protection, the anticipation and avoidance of potential harm not only benefit human health and wellbeing, but are almost always more cost-effective than later environmental clean- up and treatment of disease. Such preventive action involves many different areas of government, including agriculture, energy production, housing, industry, land use and urban planning, and transport. At present, the frequent absence of a multisectoral approach to environmental health management, and the lack of effective coordination of action, result in socioeconomic development having impacts on the environment that adversely affect the health and wellbeing of the population.

This book attempts to facilitate the rever- sal of these practices by presenting an overall picture of the effects on health of environmental conditions throughout the European Region, thus demonstrating the need for the various sectors of government and society to interact if improvements are to be made. In view of the many transfrontier environmental issues that have public health implications, the book also tries to demonstrate the need for countries to share information systems, as an objective basis for decision- making.

The European Charter emphasized that careful environmental stewardship could not only prevent adverse effects on health but also contribute towards wellbeing. It is easier to recognize wellbeing than to provide a rig- orous, scientific definition of it, and there are no satisfactory measures of the benefits of an aesthetically pleasing environment in health terms. A mutually supportive community within a diverse and sustainable ecosystem, however, bestows benefits that go

(28)

28 Introduction

beyond the prevention of individual diseases.

Epidemiology has not yet succeeded in deal- ing with these concepts, nor are there satisfactory indicators. This book tries to develop a perspective whereby enhancement is as important as prevention, although very little quantitative information is available on this difficult but important issue.

The project has shown the many shortcomings in the existing databases and systems for collection, collation, analysis and dissemi- nation. On many topics, reliable data for assessing health impacts could not be as- sembled. Much information is fragmented, incomplete and of doubtful relevance and/or validity, and does not undergo proper quality control procedures. Much is collected and remains within separate administrations at central, regional and local levels. Much monitoring seems to lack clear objectives and does not appear to be used in decision- making or environmental health management. Many single studies have been carried out that have not or cannot be replicated. An ever present danger is that only the positive results of epidemiological studies are quoted, while the results of well conducted studies leading to negative results are not taken into account.

All those taking part in the development of the project, whether at country or international level, were aware of these constraints and difficulties. From the beginning, they realized that it would not be possible to make a comprehensive assessment of environmental health for all parts of the Region.

They nevertheless considered that the objective was so important that they were fully jus- tified in making the attempt.

Limitations and Constraints

The investment that is being, and will be, committed to environmental management in the interests of human health and wellbeing is large, particularly in the context of the limited total resources available. Policies must therefore be based on sound data, and deci- sions on priorities for action should take the cost–benefit aspects into account. Better data will facilitate a proactive stance, whereby the potential effects on health of different forms of development may be pre- dicted and prevented, rather than waiting until remedial action becomes necessary, which may be very costly even if practicable.

However good the information system, data are not always available to support a particular course of action. While acknowl- edging these shortcomings, one must sometimes resist the temptation to delay action while searching for the underlying causes of problems, or for data to define their precise nature. Society must sometimes act on intu- ition based on experience. Such justification can be found in the sanitary movement in Europe during the nineteenth century, when great advances were made in controlling communicable diseases many years before the etiological agents were identified and the problems precisely identified by epidemiological science.

To obtain better data, harmonized and comparable data collection and management are clearly needed throughout the Region, based on the use of core indicators of environmental health. The national focal points have stressed that, to achieve this objective, they require technical support from the WHO European Centre for Environment and Health. Such information systems cannot be the prerogative and responsibility of only one authority. They require careful planning and continuing collaboration among the various sectors at all levels.

Further, such systems should be designed with clear objectives. Their relevance and ef-

Beyond Concern for Europe’s

Tomorrow

(29)

fectiveness can be evaluated by their ultiliz- ation in the resolution of practical issues.

The national focal points have recom- mended that (a) lessons learned from the experience of Concern for Europe’s Tomorrow be fully applied at national and international levels, and (b) the information collected be periodically updated and reviewed so as to provide a more accurate and comprehensive picture of the environment and health situation throughout the Region and, as far as possible, to predict trends.

[1] Environment and health. The European Charter and commentary. Copenhagen, WHO Regional

References

Office for Europe, 1990 (WHO Regional Publi- cations, European Series, No. 35).

[2] The work of WHO in the European Region 1980.

Copenhagen, WHO Regional Office for Eu- rope, 1981.

[3] Health for all targets. The health policy for Eu- rope. Copenhagen, WHO Regional Office for Europe, 1991 (European Health for All Series No. 4).

[4] Our planet, our health. Report of the WHO Com- mission on Health and Environment. Geneva, World Health Organization, 1992.

[5] Report of the United Nations Conference on En- vironment and Development, Rio de Janeiro, 3–14 June 1992. New York, United Nations, 1992 (document A/Conf. 151/26 (Vol. 1)).

[6] WHO Global Strategy for Health and Environ- ment. Geneva, World Health Organization, 1993 (document WHO/EHE/93.2).

[7] Environment for Europe. Ministerial Conference, Lucerne, 28–30 April 1993. Conference report.

Berne, Federal Office for the Environment, 1993.

(30)

31

Part I

Background

(31)

(32)

33

Chapter 1 Economic Sectors

This book provides a situation analysis of health and the environment in the Member States of the WHO European Region. Owing to the political changes of recent years, these countries have nearly doubled in number and their heterogeneity has become much more apparent. This chapter describes the basic economic circumstances that largely determine the conditions and chances for development in environmental health in most of these countries.

Further, this chapter briefly outlines some of the main patterns of economic activity in the Region whose growth is essential for human development. As both socioeconomic factors and the state of the environment influence health, information on overall economic development, the structure of economies and other basic data are essential to an understanding of the mutual relationships between health, the environment and economic sectors. The question as to

1.1 Introduction

whether the economic environment, production and consumption are able and willing to support sustainable development is one of the most important challenges for the future.

At the end of the twentieth century, the European Region faces major political, economic, social and environmental changes.

Many Member States are in a transitional phase in their political systems and socioeconomic development, as they move from cen- trally planned to market economies. This creates special requirements, particular possibilities and considerable constraints.

This chapter highlights some of these in relation to the environmental health situation.

1.2.1 Basic features and indicators

As of January 1994, the WHO European Re- gion had 50 Member States. Of these, 12 are

1.2 The WHO European Region

1.1 Introduction 33

1.2 The WHO European

Region 33

1.2.1 Basic features and indicators 33 1.2.2 Development of economic

activities 36

1.2.3 The CCEE and NIS 36

1.3 An Outlook for the Future 39

1.3.1 Some trends 39

1.3.2 Some scenarios 40

1.4 Energy 40

1.5 Industry 48

1.6 Agriculture 51

1.7 Transport 54

1.8 Tourism 56

1.9 Urban Development 58

1.10 Conclusions 60

References 61

(33)

described as countries of central and eastern Europe (CCEE) and 15 constitute the newly independent states (NIS) of the former USSR. Together, these two groups are often called countries or economies in transition, in reference to the enormous political, economic and social changes currently taking place (Table 1.1). While the developed market economies of the Region vary, they are referred to as western countries when being compared with the CCEE and NIS.

Using gross national product (GNP) per head, the World Bank classified the countries of the world into four major groups ac- cording to the level of their economic output [1]. No country of the European Region was in the first group, the countries with low incomes, but 16 were found in the group with lower-middle incomes (a GNP per head of US $ 636–2555) in l991. While 10 countries had upper-middle incomes (US $ 2556–

7910), 19 belonged to the high income group with a GNP per head of more than US

$ 7910 (Table 1.2).

The populations of countries in the WHO European Region range from some tens of thousands to approximately 150 million, and their areas from some tens of square kilo-

metres to about 17 million. Their economic power is also extremely diverse: the gross do- mestic product (GDP) per year ranges from some hundreds of millions of US dollars to more than US $ 1500 billion.^a Taking the GDP per head in the United States in 1991 as 100 %, the GDP per head, in purchasing power parity, in the countries of the Region was estimated to range from 10 % to nearly 99 % [1–3]. The countries differ much less in their scores on the human development index (Table 1.2), which combines three key components (income, knowledge and lon- gevity) to arrive at an average deprivation index [4]. An index of 0.80 or more indi- cates high, 0–0.79 medium, and below 0.50 low human development.

In 1991, the countries in transition had a population of about 410 million, or nearly half of the Region’s total population of 850 million. For 1991, the World Bank estimated the average GNP per head in the middle income countries of the Region as US $ 2670, with an average annual growth rate of 0.9 % in the period 1980–1991. The GNP per head

a 1 billion = 10⁹. Table 1.1: The central and eastern Member States of the WHO European Region

(34)

The WHO European Region 35

Table 1.2: Economic and development indicators for countries of the WHO European Region