The environment can have an important influence on health. The European Environment Agency (EEA) and theWHO European Centre for Environment and Health (ECEH) developed this publication as a joint effort to draw attention to some environmental issues that have a significant impact on the health of the people of Europe. It represents the logical complement and continuation of two related projects: the report Europe's environment: the Dobris assessment, published by the European Environment Agency, and Concern for Europe's tomorrow: health and the environment in the WHO European Region, published by the WHO Regional Office for Europe.
Pooling the immense amounts of data that they have gathered, EEA and ECEH have distilled the resulting knowledge into a brief discussion of the contribution of environmental factors to the main causes of death (and morbidity) in Europe, and an examination of three particularly significant issues. These three issues are not mentioned as more important than other issues, but to indicate a few areas where significant benefits can be expected through coordinated policies. These issues meet important criteria. Each is a widespread problem that causes significant damage to the health of many people throughout Europe, and all are amenable to coordinated action that would result in both improved environmental quality and health benefits within a short time. Delaying this action would increase the damage and make these problems harder to solve in the future. This report not only identifies these issues air pollution with suspended particles, the microbiological contamination of drinkingwater and road traffic accidents and sketches the harm that by they do, but lists goals and strategies for action now.
As is made clear by the review in Chapter 2 of the main health problems affecting the European population, the dominant risk factors of the most frequent severe diseases are related to behavioural and lifestyle factors (such as smoking, an unhealthy diet or excessive drinking) or to various host characteristics (such as genetic predisposition). Nevertheless, a number of environmental factors do in different degrees adversely influence the health of the European population. Thus, they contribute to health problems such as respiratory diseases, some types of cancer, gastrointestinal diseases, injuries and effects on wellbeing.
One of the most striking recent phenomena in Europe is the gap in life expectancy observed between eastern and western countries which opened in the 1960s and 1970s. By 1992, the average life expectancy in the countries of central and eastern Europe (CCEE) and the newly independent states (NIS) of the former USSR was several years less than in the rest of Europe. Overall life expectancy for both sexes was 75.6 years in the west and 69.6 in the east. In total, cardiovascular diseases are responsible for more than 50% of the present gap and external causes and respiratory diseases, for 23% and 16% respectively. From the point of view of age, the main contribution to the gap comes from the group aged 35-64 years (43%). In total, more than half of the difference is attributable to mortality at a relatively young age, with the consequent loss of human resources to society as a whole. It has been postulated that living conditions in the larger sense, through their impact on psychology and behaviour, might determine the differences in morbidity and mortality in selected groups. In this model, the environment not only has a direct impact as a vehicle of toxic exposure, but is also an intermediate variable influencing people's psychological and behavioural adjustment to the changing patterns of life.
The main findings, goals and strategies being applied to the three main problems identified are summarised below.
Pollution of air with suspended particles
Studies indicate that adverse health effects associated with suspended particulate matter (SPM) in air exist even at very low concentrations of particles. Effects are acute and most are of short duration. It is estimated that shortterm pollution episodes account for 710% of all lower respiratory illness in children and that this proportion reaches 20% in the most polluted cities. An increase in the concentration of the respirable particles (PM10) by 100 g/m3 over a threeday period is estimated: to double the number of times people with asthma experience an exacerbation of symptoms; to increase asthmatics' use of medication by 70%; to increase admissions to hospital for respiratory conditions by 20%; and to result in a 10% increase in mortality during the pollution period. Although more data are needed on longterm effects, the few existing studies conducted at the levels of pollution common in European cities show an increase in chronic pulmonary disease incidence and in mortality.
The assessment of health impacts is based on scarce exposure data and limited information on the relationship between exposure and health. Current knowledge indicates, however, that the steps necessary to reduce the health effects of SPM include: reducing emissions of fine particles, especially in highly populated areas; developing pollution control strategies both to eliminate brief periods of high concentrations and to reduce longterm average levels; and beginning to measure SPM of a specified particle size in the monitoring networks.
Microbiological contamination of drinkingwater
It has been estimated that 12% of the population in the WHO European Region, mainly in eastern countries, lacks access to safe drinkingwater. Lack of these facilities has long been recognised as a major cause of manycommunicable diseases, which remain widespread in many parts of Europe. Various types of diarrhoea and hepatitis A are the most important diseases transmitted through the microbiological contamination of water in Europe, but other diseases that result in morbidity and temporary disability are also significant and have economic consequences. The large human and financial costs of waterborne epidemics are well documented in western Europe and the United States. The domestic water supply may not only be a potential vector of communicable diseases but can also provide a protective barrier against infections by facilitating personal hygiene. Without action, the already unsatisfactory infrastructure in many parts of Europe will continue to deteriorate with increasingly serious health consequences. The extent of human exposure to chemical contaminants in Europe still needs assessment to clarify its potential impact on European populations.
The goals of action on the microbiological contamination of drinking water include: reducing the burden of waterrelated communicable diseases by interventions that have been shown to yield clear benefits, estimating the extent of human exposure and avoiding contamination of water sources. Improvements in the quality and availability of water and in the disposal of excreta have both been demonstrated to lead to major reductions in morbidity from diarrhoeal diseases (from 2025% if implemented separately, to 37% for combined interventions), improvements in nutrition and reductions in other communicable diseases. The use of coliforms at central water supply points as the only indicator of pollution does not provide sufficient information about the reasons behind contamination and may give rise to the false impression that a "chemical fix'' is the best solution. Greater emphasis needs to be given to a comprehensive consideration of all aspects of water contamination from water source to point of use. Continued international coordination is needed to define priorities and carry out the necessary investigations of the health effects of chemical contaminants.
Road traffic accidents
Although transport is considered as an important part of the economy and lifestyle of contemporary Europe, it exacts a high price from society and the environment. Transport is an important source of air and water pollution and contributes to the degradation of the landscape. The air pollution and noise emitted affect populations, particularly urban residents, reducing quality of life and promoting a range of less severe symptoms, sometimes leading to the permanent impairment of health or aggravating chronic disease. Among the most obvious, direct health effects are the deaths and injuries caused by traffic accidents. Road traffic accidents are responsible for 88% of all deaths caused by all means of transport. On average, over 6000 people are injured and about 340 people are killed on Europe's roads every day. Although deaths in traffic accidents constitute scarcely 13% of all deaths, accidents cause 1219% of all deaths in people aged 1544 years. The exceptionally high and well defined harm to health, the lack of a consistent decreasing trend in the frequency and health effects of accidents, the significant economic burden to society and the large variation in the extent of the health effects in countries of similar levels of economic development (indicating the feasibility of reducing these effects) all indicate the importance of road traffic accidents as a multisectoral issue of public health significance.
At the same time, traffic accidents cannot be separated from the broad domain of transport and its environmental effects. The goals and strategies of actions to reduce the number of accidents and the resulting injuries and deaths throughout Europe all involve important "winwin" measures, which reduce accidents, environmental pollution, energy consumption and road congestion. It is coming to be recognised that transport policy needs comprehensive revision in the long term, to reduce the adverse effects of road traffic on both the environment and health. More fundamental policies being considered address the very demand for transport and focus on solutions affecting the whole system, such as the reduction of the need for population movement, the provision of good and accessible public transport and the design of improved cargo flows. This is an especially urgent task in the CCEE and NIS, where improvements in the traffic infrastructure and the behaviour of drivers and pedestrians have not balanced the rapidly growing traffic density.
In conclusion, this report shows that much still needs to be done to satisfy the basic human right to a healthy environment. For the three issues highlighted in particular, much can be done to alleviate the problems and the consequent impacts on human health. This short report is intended to raise awareness about the problems and to provide arguments so that urgent decisions and actions can be taken to combat the impact of environmental problems on human health.
For references, please go to www.eea.europa.eu/soer or scan the QR code.
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