Health and Environment in Europe: Progress Assessment

This text is taken from the WHO report "Health and Environment in Europe: Progress Assessment", 2010, ISBN 978 92 890 4198 0. [1]

This report describes the progress made by the Member States of the World Health Organization (WHO) European Region in their health and environment situation over the last 20 years. The assessment focuses on the environment and health issues arising from the four regional priority goals of the Children’s Environment and Health Action Plan for Europe (CEHAPE), agreed at the Fourth Ministerial Conference on Environment and Health in Budapest in 2004. The indicators selected for the European Environment and Health Information System (ENHIS) are the main tool of the analysis. The status of policies on environment and health is evaluated using the data submitted by 40 Member States responding to the WHO survey on environment and health policies conducted early in 2009, and the responses of 42 countries to the web-based survey on CEHAPE conducted in November 2009.

The analysis of the data on water-related risks to health concluded that population access to improved water sources, sanitation and wastewater treatment has increased over the past two decades in most, but not all, Member States. In many countries in the east of the Region progress is slow: more than 50% of the rural population in 10 countries have no access to improved sources of water, giving rise to important health inequalities. Disease outbreaks related to drinking-water are registered even in the most economically developed countries indicating that unsafe water remains a public health issue throughout the Region. Harmonized surveillance systems for waterborne diseases and outbreaks are still absent in a majority of the countries in the Region, as are systems for monitoring health risks related to bathing water.

European Community legislation on water and health is an important policy driver throughout the Region, including in areas beyond the European Union (EU). The United Nations Economic Commission for Europe (UNECE)/WHO Protocol on Water and Health has become the Region-wide health regulation in the areas of integrated water resource management, a sustainable water supply compliant with WHO’s guidelines for drinking-water quality and adequate sanitation for all.

Unintentional injuries are a leading cause of death in young people aged 0–19 years, with road traffic injuries contributing the largest burden followed by injuries occurring in the home and in leisure settings. Inequalities between countries are extreme, with mortality and injury incidence rates differing by an order of magnitude between countries. The substantial overall reduction in traffic-related deaths over the last two decades shows that these injuries and deaths are preventable. Unfortunately, in the last decade this downward trend has halted in countries in the east of the Region, where a small increase in mortality has been recorded, increasing the gap between the rates for the newly independent states and EU countries to over 50% of the EU level.

There are wide variations in the national proportions of overweight and obese children, ranging from 3% to over 30% in 11–15-year-olds. In many countries, the problem appears to be worsening in the recent years. At the same time, a substantial proportion (40–50% or more) of 11-year-olds in all countries in the Region do not engage in sufficient physical activity; the proportion is even higher among 13- and 15-year-olds.

There is growing evidence that well-designed built environments and public green spaces enhance physical activity patterns and reduce the risk of injuries. Tailored approaches are required for specific groups of citizens to benefit from the full potential of public places and networks to exercise and be physically active, and to be protected from threats to their safety in the urban, transport, home and leisure environments.

The incidence of infant deaths from respiratory disease has been falling in most countries but is still a significant health burden (12% of infant deaths overall), particularly in the eastern part of the Region. From 5% to 25% of children aged 13–14 years suffer from asthma and allergies, indicating that these diseases are an important and increasing cause of childhood illness in the Region. Air pollution, especially inhalable particulate matter (PM10), exacerbates asthma symptoms and recent studies indicate that it can also contribute to the incidence of the disease.

Urban air pollution, especially particulate matter, also causes other significant health problems throughout the Region, reducing the life expectancy of residents of more polluted areas by over one year. After substantial decreases in outdoor air pollution in most of the Region in the 1990s, progress in the last decade has been minimal. Over 92% of the urban population for whom relevant air quality data are available live in cities where the WHO air quality guideline for PM10 is exceeded.

In many countries, over 80% of children are regularly exposed to second-hand tobacco smoke in the home and even more outside the home. Although regulations introducing spaces free of tobacco-smoke, following the principles of the Framework Convention on Tobacco Control, have proved highly efficient in reducing the impacts on health of tobacco, they have yet to be introduced or developed in large parts of the Region.

Dampness and mould are now established as major indoor air quality problems that disproportionately affect the health of disadvantaged populations. More than 20% of households live in houses where dampness and mould are evident. Although approaches to reduce and eliminate these problems from buildings are available, the relevant public policies need to be strengthened. The newly published Indoor air quality guidelines should raise awareness of this issue in the Member States.

Policies and action to limit exposure to persistent organic pollutants and heavy metals in food and to eliminate exposure to lead have achieved considerable success within the Region. Lead emissions decreased by 90% between 1990 and 2003, mainly due to the complete switch to unleaded gasoline in most of the Region. This has been reflected in a lower level of lead in children’s blood. Leaded petrol is, however, still being used in some countries and exposure remains of health concern in populations living near industrial hot-spots in the east and south-east of the Region. A full assessment of population exposure to heavy metals is difficult owing to the scarcity of bio-monitoring data.

International cooperation on food safety has been efficient, with countries developing coherent standards and regulations and thus ensuring the same level of health protection for a substantial proportion of the European population. Environmental policies on heavy metals do not, however, give much consideration to health in most countries, and certainly not proportional to the risks to health which such metals may create.

Environmental noise is perceived as the most common stressor: a quarter of the population in EU countries are exposed to noise levels leading to a wide range of health effects. Noise abatement policies in many Member States need to be strengthened to address health problems effectively. Safety in the occupational environment improved significantly in the 1990s but, in the last decade, the improvement has levelled off in the eastern part of the Region.

Relevant data and information have become significantly more available and accessible over the last decade, to a large extent due to the new requirements for improved monitoring and data exchange between the Member States (resulting from EU legislation or international conventions) and to activities coordinated by the European Environment Agency and WHO. The establishment of ENHIS has provided an important and efficient tool for situation analysis. Nevertheless, data are far from comprehensively available. The lack of relevant monitoring in large parts of the Region restricts the possibility of a comprehensive Region-wide assessment of the situation.

In the case of several old problems, such as outdoor air pollution, many countries have exhausted simple measures to control hazardous emissions and need to turn to more complicated, systemic approaches to bring down population exposure levels further. Local measures are not sufficient, and regional and international action is needed to achieve further progress in reducing pollution. In the eastern part of the Region, air quality management systems have not been adapted to the changing evidence base and identification of inhalable particles as a prominent and widespread health risk.

The scope of public policies varies significantly as regards environmental health issues. While traditional hazards, such as those related to drinking- and bathing water, are subject to a broad range of activities and include substantial involvement by health systems, issues related to indoor air quality, the prevention of unintentional injuries or promotion of physical activity are some of the topics for which policies are less developed.

The regulatory basis for action has improved significantly in recent years. International regulations, such as new directives on air quality or on the management of chemicals, have been introduced in the EU and are also followed in many non-EU countries in the Region. In non-EU countries, more than half of the regulatory acts related to the environment and health have been created, revised or updated in the last five years. For example, the UNECE/WHO Protocol on Water and Health supports health-related regulations in the areas of integrated water resource management and sustainable water supply throughout the Region; the Framework Convention on Tobacco Control promotes new action to reduce exposure to second-hand tobacco smoke; and the Strategic Approach to International Chemicals Management provides a new framework for chemical safety.

There are wide variations in the inclusion of population health between policies addressing different topics. Health is well considered in policy development in most parts of the Region in relation to drinking-water, outdoor air quality or food safety, but there are substantial differences between various parts of the Region in relation to policies on bathing water. Explicit consideration of health in the development of policies is still rare in relation to unintentional injuries, physical activity or heavy metals. However, where issues such as unintentional injuries, physical activity or exposure to second-hand tobacco smoke are concerned, health systems are involved in implementing policy even though health is not explicitly considered during the formulation of policy.

The extent, methods of implementation and enforcement of policies related to the quality of drinking- and bathing water, unintentional injuries, physical activity, outdoor air quality, second-hand tobacco smoking or environmental noise vary widely between groupings of countries. In general, penalties for infringement of regulations are more often used in the east of the Region and action plans to reduce the risks more common in the west.

There is less accountability for health in policies on dampness and mould, heavy metals and noise than on other topics, as well as, in some groupings of countries, for unintentional injuries and physical activity. The level of accountability corresponds to the existence and efficiency of health-relevant monitoring systems and use of the available information for policy evaluation. The lack of reliable monitoring systems generating data on widespread environmental health issues, such as outbreaks of waterborne diseases or inhalable particulate matter, remains a problem in many countries of the Region.

Most countries involved their health systems in implementing policies regarding drinking-water, second-hand tobacco smoke and food safety. Such involvement varied significantly between countries for most other topics; this could, to some extent, be a reflection of differing distributions of responsibilities within the public sector. In some cases, however, less involvement by health systems could be due to inadequate resources and capacity in the health system.

In most countries, little attention is paid to the special needs of vulnerable groups in relation to all the topics considered except unintentional injuries or physical activity. Social inequalities or gender issues are relatively rarely addressed in those policy- and decision-making processes of relevance to children’s environment and health. This may increase social inequalities in exposure and related health risks.

Despite overall progress in the collection and use of environment and health data, the availability of information to prioritize, monitor and assess the effectiveness of action is unequal across the Region. This hampers the effective use of resources and militates against sustainable action. The information available to the public is limited, lessening their involvement in risk reduction and their support for policies addressing the environmental determinants of health. The scarcity of data reduces the possibility of carrying out risk analyses, setting priorities for action and monitoring their implementation.

Two thirds (28) of the 42 countries that responded to the CEHAPE survey have developed, and a further 10 are developing, a national or sub-national children’s environment and health action plan, mainly as a component of other national policies or of the national environment and health action plans. In most countries, the European policy framework (CEHAPE) has positively influenced interventions to reduce the environmental risks to children’s health, the development of monitoring and information systems in environment and health, public information and awareness and intersectoral collaboration. In a quarter of the responding countries, however, the European plan has failed to mobilize human and/or financial resources for environment and health issues, or to stimulate capacity-building or collaboration with other countries that share similar problems.

The availability of skilled human resources, supported by a stable institutional base, is a key factor in limiting the ability to plan and implement action to improve the environmental health situation, especially in the eastern parts of the Region. When intersectoral collaboration is inadequate and ineffective, the capacity to address old problems and identify emerging ones is further restricted. The lack of a sustainable mechanism to ensure such collaboration, in particular the absence of dedicated budgets or a too informal character, make both the collaboration and the pooling of resources difficult.

Introduction

Good health and well-being require a clean and harmonious environment where physical, psychological, social and aesthetic factors are all given their due importance. These factors are affected by actions and choices which can secure considerable health benefits. The environment is thus not only important for its own sake, but as a resource for better living conditions and well-being.

The socioeconomic and political upheavals in the World Health Organization (WHO) European Region two decades ago had huge implications for human health and the environment. There was then major concern, in both the east and the west, about poor environmental quality and its current and future impact on people’s health. Moreover, this burden was then (as now) distributed unequally within and between areas, with less affluent countries facing major environmental problems.

We should perhaps not, therefore, be surprised that the breaking of this political log-jam released enormous potential for internationally concerted action on environment and health. As early as 1989, at the First Ministerial Conference on Environment and Health,1 a major policy framework had emerged – the European Charter on Environment and Health (1) – which defined the essential prerequisites of public policy in environment and health and set out a strategic vision for Region-wide joint action.Taking encouragement from the many examples of pollution reduction measures already taken and the restoration of healthy environments, the Charter set out the main principles, mechanisms and priorities for protecting and restoring the environment and improving health.

Since then, every five years, ministerial conferences have reviewed progress and developed and agreed policies under the Charter. The Fourth Ministerial Conference (held in Budapest in 2004) emphasized the needs of vulnerable groups and intergenerational issues by adopting the Children’s Environment and Health Action Plan for Europe (CEHAPE). CEHAPE set the direction for health and environment action for children via four Region-wide priority goals. These goals not only address the most important environmental public health issues, in both scale and spread, but are also highly amenable to action. Taken together, they provide a valuable framework for assessing and promoting progress on the benefits for children flowing from the provision of healthy and safe environments for them.

In the early 1990s, the document Concern for Europe’s tomorrow (2) was the first major general assessment of health and the environment in the European Region. Decisions taken then are still bearing fruit. The report highlighted the urgent need for action on environment and health (EH) information to support relevant decision-making. That recognition helped to stimulate subsequent advances in environmental monitoring, greater appreciation of its health relevance, strengthening of the EH evidence-base and a greater understanding of how to make best use of this evidence.

As a result, it is now possible to assess the effectiveness of policy measures, and to set and adjust priorities in ways that were impossible two decades ago. Now in 2010 this progress assessment report:

• assesses national progress in implementing priority EH issues arising from the four CEHAPE regional priority goals agreed at Budapest in 2004;
• provides an update on general trends and developments in the environment and health situation in the Region;
• summarizes the status of policies on selected environmental health issues using data submitted by 40 Member States responding to the WHO survey on EH policies conducted early in 2009, and the responses from 46 Member States to the web-based survey on CEHAPE conducted in November 2009 (countries responding to the surveys are listed in Annex 1).

Objectives of the report and questions it answers

The assessment is organized in five sections: four of these correspond to the regional priority goals and the fifth explores the status of national CEHAPE programmes and mechanisms to facilitate their implementation such as intersectoral collaboration. All sections relating to the regional priority goals consist of (a) an indicator-based assessment of health and the environment in the Region, and (b) an analysis of policy profiles according to public governance and healthy public policy mechanisms.

The indicator-based assessments in the sections on the regional priority goals seek to provide information about health determinants and the economic sectors and activities creating environmental problems with their associated health consequences. This is where interventions are necessary to deliver health benefits, although policy development and implementation has rarely, if ever, been under the direct control of the health sector. Indicators used in this analysis are mostly those included in the Environment and Health Information System (ENHIS), developed by WHO in collaboration with partner institutions in 18 countries, with support from the European Commission, as part of the follow-up to the Budapest Conference. Full analysis of each indicator is presented on ENHIS fact sheets, available on the Environment and Health Information System web site (3).The topics covered by the fact sheets are listed in Annex 2.

For each regional priority goal, the EH situation assessment analysis addresses the following questions.

• What is the magnitude and severity of the selected public health problems and their distribution within the Region? How preventable are they, and what is the potential for improving health?
• What is the current situation regarding environmental risk factors that contribute to public health problems? What progress has been made since the Budapest Conference and over the last 20 years? What are the differences between and within countries? How do social inequities affect the range of outcomes?

The policy analysis highlights progress in EH policy development and implementation, including the empowerment of national health systems and the integration of EH health issues across government policies and departments. It addresses the following topics.

• Public governance. The assessment is based on analysis of:
  • policy development in terms of regulatory instruments used and when they were introduced; the policy drivers, objectives and scope of measures; and the approach to target-setting;
  • implementation and enforcement of policy, including an evaluation of the means of defining compliance, where responsibility lies for implementation and enforcement, and measures taken in cases of non-compliance.
• The analysis is based on data from 42 countries. Responses from four countries were received after the analysis of survey data conducted for this report was completed.
• Healthy public policy: how public health is integrated into the policy. This evaluates:
  • accountability for health, presenting mechanisms for maintaining government and other resource controllers’ accountability to the public for the health consequences of their policies (or lack thereof), including the existence of health-relevant environmental monitoring, tracking policy progress and assessing and reporting the health impact of policy action;
  • involvement of the health sector throughout the cycle of policy development and implementation, including public health monitoring and assessment of the health impact of policies; and the involvement of health professionals in providing information to the public and in control and enforcement of policy;
  • equity considerations of the policies, notably towards children and other vulnerable and underprivileged groups, and whether there are policy measures and action plans specifically aimed at their protection.
• Transparency and communication explores approaches to the provision of public information on health promotion, education and risk awareness, including an assessment of how easy it is for the public to encounter information, access the media channel and understand the messages.

In the cases of regional priority goals I, II and III, the potential benefits to health of various strategies that attempt to adapt or alleviate the consequences of climate change are also highlighted.

Country groupings

The country groups used in this analysis are informal groupings that correspond broadly to countries’ recent history and current political situation, as follows:

• EurG-A: the EU member states before 1 May 2004 (EU15), Andorra and the European Free Trade Association countries (17 countries responded to the survey);
• EurG-B: the EU member states who joined after 1 May 2004 (EU12) (10 countries responded to the survey);
• EurG-C: Albania, Bosnia and Herzegovina, Croatia, Israel, Montenegro, Serbia,3 The former Yugoslav Republic of Macedonia and Turkey, a diverse grouping that includes countries in the south and east of the Region with differing histories and political arrangements: some are EU candidate countries and others are potential EU candidates (6 countries responded to the survey);
• EurG-D: countries formerly part of the Soviet Union, other than the Baltic States – Armenia, Azerbaijan, Belarus, Georgia, Kazakhstan, Kyrgyzstan, Republic of Moldova, Russian Federation, Tajikistan, Turkmenistan, Ukraine and Uzbekistan (7 countries responded to the survey).

Figure below presents the respondents to the WHO policy survey from each grouping.

Methods of policy survey and policy analysis

The questionnaire addressed 16 specific topics covering the scope of the four regional priority goals. It was designed by invited WHO experts, reviewed by a WHO Working Group meeting in May 2008, and tested by countries that volunteered to do so in the summer of 2008. The updated version of the questionnaire (in English and Russian) was presented to the Second High Level Meeting in Madrid (October 2008) for approval.

The final version of the questionnaire was distributed to the EH focal points in the Member States in November 2008 with the aim of collecting the information by February 2009. According to the survey manual, the focal points could (and in most cases did) distribute parts of the questionnaire addressing specific topics to national experts, often in sectors other than health. This increased the reliability of the answers and multisectoral assessment of the policies.

WHO European Region Member States who responded to the WHO survey on environment and health policies, by grouping, 2009

Contents of the report

This report consists the following five sections:

• Clean water - a basic human right
• Be mobile, active - and safe!
• Clean air for health
• Eliminating environmental health hazards
• Implementing the CEHAP for Europe:the role of intersectoral collaboration
• Annexes

Conclusions of the assessment

Analysis of the information accumulated in the ENHIS system and of the responses