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Environmental health inequalities in Europe: assessment report

1 janvier 2012 Organisation mondiale de la santé

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Recent debate on the social determinants of health has indicated that the unequal distribution of health and well-being in national populations is a major challenge for public health governance. �is is equally true for environmental health condi- tions and for exposure to environmental risk, which varies strongly by a range of sociodemographic determinants and thus causes inequalities in exposure to – and potentially in disease resulting from – environmental conditions.

Interventions tackling such environmental health inequalities need to be based on an assessment of their magnitude and on the identi�cation of population groups that are most exposed or most vulnerable to environmental risks. However, data to quantify the environmental health inequality situation are not abundant, making comprehensive assessments di�cult at both national and international levels. Following up on the commitments made by Member States at the Fifth Ministe- rial Conference on Environment and Health in Parma, Italy (2010), the WHO Regional O�ce for Europe has carried out a baseline assessment of the magnitude of environmental health inequality in the European Region based on a core set of 14 inequality indicators. �e main �ndings of the assessment report indicate that socioeconomic and demographic inequalities in risk exposure are present in all countries and need to be tackled throughout the Region. However, the report also demonstrates that each country has a speci�c portfolio of inequalities, document- ing the need for country-speci�c inequality assessments and tailored interventions on the national priorities.

World Health Organization Regional Office for Europe

Scherfigsvej 8, DK-2100 Copenhagen Ø, Denmark Tel.: +45 39 17 17 17. Fax: +45 39 17 18 18 E-mail: contact@euro.who.int Web site: www.euro.who.int

The WHO European Centre for Environment and Health, Bonn Office, WHO Regional Office for Europe, coordinated the development of this report.

Abstract Recent debate on the social determinants of health has indicated that the unequal distribution of health and well-being in national populations is a major challenge for public health governance. This is equally true for environmental health conditions and for exposure to environmental risk, which varies strongly by a range of sociodemographic determinants and thus causes inequalities in exposure to – and potentially in disease resulting from – environmental conditions. Interventions tackling such environmental health inequalities need to be based on an assessment of their magnitude and on the identification of population groups that are most exposed or most vulnerable to environmental risks. However, data to quantify the environmental health inequality situation are not abundant, making comprehensive assessments difficult at both national and international levels. Following up on the commitments made by Member States at the Fifth Ministerial Conference on Environment and Health in Parma, Italy (2010), the WHO Regional Office for Europe has carried out a baseline assessment of the magnitude of environmental health inequality in the European Region based on a core set of 14 inequality indicators. The main findings of the assessment report indicate that socioeconomic and demographic inequalities in risk exposure are present in all countries and need to be tackled throughout the Region. However, the report also demonstrates that each country has a specific portfolio of inequalities, documenting the need for country-specific inequality assessments and tailored interventions on the national priorities.

Keywords ENVIRONMENTAL HEALTH ENVIRONMENTAL EXPOSURE HEALTH STATUS DISPARITIES SOCIOECONOMIC FACTORS RISK FACTORS RISK ASSESSMENT EVALUATION STUDIES EUROPE

ISBN 978 92 890 0260 8

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Environmental health inequalities

in Europe

Assessment report

CONTENTS Contributors ��vii

Acknowledgements �� xi

Foreword �� xiii

Executive summary ��xv

Introduction ��2 Rationale for health inequality assessment and monitoring ��2 Assessing environmental health inequalities in the WHO European Region ��3 Rationale and overview of the project ��4 Benefits of inequality assessments for action��5 Overview of report ��7 Methodological notes ��8 Data access �� 10 References�� 10

Chapter 1. The concept of environmental health inequalities �� 14 A historic perspective �� 14 Inequality and inequity �� 15 Identification and assessment of inequalities and inequities �� 15 Environmental health inequality: hazard and risk �� 16 Sociodemographic factors, exposure and vulnerability �� 17 The psychosocial dimension in environmental health inequality �� 17 Framing the problem �� 18 Conclusion �� 19 References�� 20

Chapter 2. Housing-related inequalities �� 22 Introduction �� 23 Data and methods �� 24 Restrictions and data limitations �� 25 Inequalities in inadequate water supply �� 26 Inequalities in lack of a flush toilet in the dwelling �� 30 Inequalities in lack of a bath or shower in the dwelling �� 34 Inequalities in overcrowding �� 37 Inequalities in dampness in the home �� 40 Inequalities in keeping the home adequately warm �� 43 Inequalities in keeping the home adequately cool �� 47 Conclusion on housing-related inequalities �� 48 References�� 49

Chapter 3. Injury-related inequalities �� 54 Introduction �� 55 Data and methods �� 56 Restrictions and data limitations �� 58 Inequalities in work-related injuries �� 58 Inequalities in fatal road traffic injuries (RTIs) �� 63 Inequalities in fatal poisoning �� 69 Inequalities in fatal falls �� 75 Conclusion on injury-related inequalities �� 79 References�� 80

Chapter 4. Environment-related inequalities ��86 Introduction ��87 Data and methods ��88 Data restrictions and limitations ��91 Inequalities in noise exposure at home ��92 Inequalities in lack of access to recreational or green areas ��95 Inequalities in second-hand smoke exposure at home ��101 Inequalities in second-hand smoke exposure at work ��105 Conclusion on environment-related inequalities ��110 References��111

Chapter 5. Gaps in evidence and restrictions on assessing environmental health inequalities ��116

Introduction ��116 Missing data ��116 Limited stratification by sociodemographic determinants ��117 Data quality ��117 Consistency and comparability ��118 Access to data ��119 Cumulative and multiple exposures ��119 Country priorities ��119 Data gaps and relevance for public health��120 Conclusion ��121 Reference ��121

Chapter 6. Priorities for action on environmental health inequalities ��124 Introduction ��124 Suggested subregional priorities for action ��124 Suggested priorities for national action ��125

Conclusion ��130 Key messages ��130 Further perspectives for action ��132 Reference ��134

Annex 1. National environmental health inequality fact sheets ��136

Annex 2. Examples of national practices in analysis and presentation of environmental health inequalities ��152

Annex 3. Assessment of priority areas for national action ��180

Annex 4. Country abbreviations ��188

Annex 5. Abbreviations ��190

Environmental health inequalities in Europe vii

CONTrIbuTOrS

Editorial group and authors Gabriele Bolte, Department of Occupational and Environmental Epidemiology, Bavarian Health and Food Safety Authority, Munich, Germany Matthias Braubach, Living Environments and Health, WHO European Centre for Environment and Health, Germany Nita Chaudhuri, American University of Paris, France Séverine Deguen, Department of Epidemiology and Biostatistics, EHESP School of Public Health, Rennes, France Jon Fairburn, Institute for Environment, Sustainability and Regeneration, Staffordshire University, United Kingdom Ingrid Fast, Maastricht University, Netherlands Lucia Isabel Fiestas, Department of Occupational and Environmental Health, EHESP School of Public Health, France Paata Imnadze, National Centre for Disease Control and Public Health, Georgia Lucie Laflamme, Department of Public Health Sciences, Karolinska Institutet, Sweden Francesco Mitis, Violence and Injury Prevention, WHO Regional Office for Europe, Denmark George Morris, Consultant in Ecological Public Health, United Kingdom Denis Zmirou-Navier, Department of Occupational and Environmental Health, EHESP School of Public Health, Rennes, France

Reviewers Maria José Carroquino, Instituto de Salud Carlos III/WHO Collaborating Centre for the Epidemiology of Environment Related Diseases, Spain Hanneke Kruize, National Institute for Public Health and the Environment (RIVM), Netherlands Anna Paldy, National Institute of Environmental Health, Hungary Kieron Stanley, Environment Agency, United Kingdom Rebecca Steinbach, Social and Environmental Health Research, London School of Hygiene and Tropical Medicine, United Kingdom

Contributors of national fact sheets and practice examples

Fact sheets Dwellings supplied with piped water by proportion of Roma population (Hungary): Anna Paldy, National Institute of Environmental Health, Hungary Attila Juhasz and Csilla Nagy, Health Organization of Government Office of the Capital City Budapest, Hungary

Lack of flush toilet by wealth status, urban/rural residence and region (Georgia): Paata Imnadze, National Centre for Disease Control and Public Health, Georgia

Lack of bath or shower in dwelling by urban/rural population and region (Kyrgyzstan): Ainash Sharshenova, Scientific and Production Centre for Preventive Medicine, Kyrgyzstan

Overcrowding by tenure group and household income (Great Britain): George Morris, Consultant in Ecological Public Health, United Kingdom Bob Gilmour, School of Engineering and the Built Environment, Glasgow Caledonian University, Scotland Jake Wilson, School of Engineering and the Built Environment, Glasgow Caledonian University, Scotland

viii Contributors

Dampness in dwelling by age, income and household type (Norway): Randi Jacobsen Bertelsen and Berit Granum, Division of Environmental Medicine, Norwegian Institute of Public Health, Norway Tor Morten Normann, Statistics Norway, Norway

Lack of home heating by education and household composition (Serbia and Montenegro): Dragana Vujanovic, Office for Sustainable Development of Insufficiently Developed Areas, Serbia

Work-related injuries by sex and economic sector (Croatia): Goranka Petrović, Department of Physiology, Monitoring and Improvement of Nutrition, Croatian National Institute of Public Health, Croatia

Transport-related mortality by sex and age (Malta): Roberto DeBono, Environmental Health Policy Coordination Unit, Ministry of Health, the Elderly and Community Care, Malta

Mortality from accidental poisoning by age and urban/rural residence (Poland): Krzysztof Skotak, National Institute of Public Health – National Institute of Hygiene, Poland

Mortality from falls by age and sex (Romania): Alexandra Cucu, National Centre for Health Promotion and Evaluation, National Institute of Public Health, Romania

Exposure to traffic noise within residential areas by household income level (Netherlands): Hanneke Kruize, National Institute for Public Health and the Environment (RIVM), Netherlands

Lack of access to recreational/green space by region (Spain): Maria José Carroquino, Instituto de Salud Carlos III/WHO Collaborating Centre for the Epidemiology of Environment Related Diseases, Spain

Potential smoke exposure at home by SES (Germany): Christiane Bunge, Environmental Hygiene, Federal Environment Agency, Germany

Exposure to second-hand smoke at work by sex, age, income, and employment (Italy): Andrea Ranzi, Environmental Health Reference Centre, Regional Agency for Environmental Prevention of the Emilia Romagna (ARPA), Italy

Practice examples Environmental health inequality action in France: a report on the SIGFRIED Project: Julien Caudeville and Celine Boudet, National Institute for Industrial Environment and Risks (INERIS), France

The United Kingdom sustainable development indicators: reporting on environmental health inequalities: Kieron Stanley, Environment Agency, United Kingdom

Identification of environmental health inequalities in populations living close to waste disposal sites in Italy: Andrea Ranzi, Regional Reference Centre on Environment and Health, Regional Agency for Environmental Prevention of Emilia Romagna Region, Italy Chiara Badaloni and Francesco Forastiere, Department of Epidemiology, Lazio Regional Health Service, Italy Giuseppe Costa, Department of Biological and Clinical Sciences, University of Turin, Italy Marco Martuzzi, Health Impact Assessment, WHO European Centre for Environment and Health Francesco Mitis, Violence and Injury Prevention, WHO Regional Office for Europe, Denmark

Assessing and reporting on environmental health inequalities related to lack of heated space and indoor pollution in Serbia and Montenegro: Dragana Vujanovic, Office for Sustainable Development of Insufficiently Developed Areas, Serbia

Analysis and presentation of environmental health inequalities concerning “green space” in Scotland: George Morris, Consultant in Ecological Public Health, United Kingdom Jon Fairburn, Institute for Environment, Sustainability and Regeneration, Staffordshire University, United Kingdom

Environmental health inequalities in Europe ix

Assessment of environmental health inequalities in Finland: residential exposure to ambient air pollution from wood combustion and traffic: Pauliina Taimisto, Marko Tainio, Jouni T. Tuomisto and Matti Jantunen, National Institute for Health and Welfare (THL), Finland Niko Karvosenoja, Kaarle Kupiainen and Petri Porvari, Finnish Environment Institute (SYKE), Finland Ari Karppinen and Leena Kangas and Jaakko Kukkonen, Finnish Meteorological Institute (FMI), Finland

Environmental health inequality report on the impact of socioeconomic status on the prevalence of allergies and respiratory diseases and symptoms in Hungarian children: Anna Paldy, Peter Rudnai, Mihaly Janos Varro, Annamaria Macsik and Eszter Szabo, National Institute of Environmental Health, Hungary Attila Juhasz and Csilla Nagy, Health Organization of Government Office of the Capital City Budapest, Hungary

Participants of project-related WHO meetings on environmental health inequality Randi Jacobsen Bertelsen, Division of Environmental Medicine, Norwegian Institute of Public Health, Norway Gabriele Bolte, Department of Occupational and Environmental Epidemiology, Bavarian Health and Food Safety Authority, Munich, Germany Celine Boudet, National Institute for Industrial and Environment and Risks (INERIS), France Christiane Bunge, Environmental Hygiene, Federal Environment Agency, Germany Krunoslav Capak, Environmental Health Ecology Service, National Institute of Public Health, Croatia Maria José Carroquino, Instituto de Salud Carlos III/WHO Collaborating Centre for the Epidemiology of Environment Related Diseases, Spain Julien Caudeville, National Institute for Industrial Environment and Risks (INERIS), France Giuseppe Costa, Department of Biological and Clinical Sciences, University of Turin, Italy Alexandra Cucu, National Centre for Health Promotion and Evaluation, National Institute of Public Health, Romania Aryuna Dashitsyrenova, Ministry of Health and Social Development, Russian Federation Roberto DeBono, Environmental Health Policy Coordination Unit, Ministry of Health, the Elderly and Community Care, Malta Séverine Deguen, Department of Epidemiology and Biostatistics, EHESP School of Public Health, Rennes, France Martin Devine, Health Services Executive, Ireland Nita Chaudhuri, American University of Paris, France Jon Fairburn, Institute for Environment, Sustainability and Regeneration, Staffordshire University, United Kingdom Berit Granum, Division of Environmental Medicine, Norwegian Institute of Public Health, Norway Paata Imnadze, National Centre for Disease Control and Public Health, Georgia Matti Jantunen, Department of Environmental Health, National Institute of Health and Welfare, Finland Hanneke Kruize, National Institute for Public Health and the Environment (RIVM), Netherlands Lucie Laflamme, Department of Public Health Sciences, Karolinska Institutet, Sweden George Morris, Consultant in Ecological Public Health, United Kingdom Anna Paldy, National Institute of Environmental Health, Hungary Rifat Pamuk, Ministry of Health, Turkey Goranka Petrović, Department of Physiology, Monitoring and Improvement of Nutrition, Croatian National Institute of Public Health, Croatia Andrea Ranzi, Regional Reference Centre on Environment and Health, Regional Agency for Environmental Prevention of Emilia Romagna Region, Italy Anne Reneflot, Norwegian Institute of Public Health, Norway Ainash Sharshenova, Scientific and Production Centre for Preventive Medicine, Kyrgyzstan Krzysztof Skotak, National Institute of Public Health – National Institute of Hygiene, Poland Kieron Stanley, Environment Agency, United Kingdom Rebecca Steinbach, Social and Environmental Health Research, London School of Hygiene and Tropical Medicine, United Kingdom

x Contributors

Dragana Vujanovic, Office for Sustainable Development of Insufficiently Developed Areas, Serbia Denis Zmirou-Navier, Department of Occupational and Environmental Health, EHESP School of Public Health, Rennes, France Ingrid Zurlyté, Centre for Health Education and Disease Prevention, Lithuania

Meeting observers Charles Price, Directorate General for Health and Consumer Protection, European Commission, Luxembourg James Wilson, School of Built and Natural Environment, Glasgow Caledonian University, Scotland

WHO secretariat Matthias Braubach, Living Environments and Health, WHO European Centre for Environment and Health1

Andrey Egorov, Environment and Health Surveillance, WHO European Centre for Environment and Health Ingrid Fast, Student intern, WHO European Centre for Environment and Health Stefanie Fleischmann, Student intern, WHO European Centre for Environment and Health Johanna Hanefeld, Social Determinants of Health, WHO European Office for Investment for Health and Development Rokho Kim, Occupational Health, WHO European Centre for Environment and Health Michal Krzyzanowski, Head of Office, WHO European Centre for Environment and Health Marco Martuzzi, Health Impact Assessment, WHO European Centre for Environment and Health Srdan Matic, Coordinator Environment and Health, WHO Regional Office for Europe Geraldine McWeeney, Environment and Health, WHO Country Office, Serbia Francesco Mitis, Violence and Injury Prevention, WHO Regional Office for Europe Angelika Nöcker, Programme Assistant, WHO European Centre for Environment and Health Deepika Sachdeva, Programme Assistant, WHO European Centre for Environment and Health Steffen Uffenorde, Student intern, WHO European Centre for Environment and Health Tanja Wolf, Climate Change and Health, WHO European Centre for Environment and Health

1 Project leader�

Environmental health inequalities in Europe xi

ACKNOwlEdGEmENTS

The project and the two related expert meetings were supported by funds generously provided to WHO by the German Government through the Federal Ministry for the Environment, Nature Conservation and Nuclear Safety.

xii

Environmental health inequalities in Europe xiii

FOrEwOrd

In 2008, the final report of the WHO Commission on Social Determinants of Health2 concluded that inequalities in health are a major challenge for both development and overall progress in countries. Such inequalities also exist within environmental health; almost all countries have some groups of their population at greater risk of experiencing harmful environmental conditions than others. Socioeconomic variables such as income, employment or occupation and education are found to be especially strong determinants of environmental health risks. Demographic variables such as age, sex and ethnicity can also affect risk, and in addition can modify the relationship between socioeconomic status, environment and health. The Member States of the WHO European Region declared their commitment to act on socioeconomic and gender inequalities in the human environment and health at the Fifth Ministerial Conference on Environment and Health in Parma, Italy, in March 2010.3

This assessment report indicates that environmental health inequalities exist in all subregions and in all countries of the WHO European Region, even though countries may have different patterns of exposure and risk. The report also confirms the expectation that often, although not exclusively, exposure to environmental risks is more frequently suffered by disadvantaged population groups.

The report shows that more and better data on the distribution of environmental risks within the population of the WHO European Region are needed. For many environmental health inequalities covered in this report, data are only available for about half the countries. The assessment of environmental inequalities is further restricted by a frequent lack of data on population subgroups defined by various categories of socioeconomic or demographic variable. This report must therefore be considered an initial baseline assessment using data available from international databases. Clearly, more work is needed to provide more and better data, enabling more insightful assessments.

The existence of significant unjust and avoidable inequalities in environmental risks within a country is not acceptable, and evidence of such inequalities, as presented in this report, thus calls for relevant policies and interventions. In consequence, the environmental health inequalities identified in the respective countries need to be validated and interpreted in the given national context, allowing the design of intersectoral remedial actions4 as well as the integration of health equity considerations into all national policies.5 Such interventions would prove that Member States have not only the capacity to identify inequalities in environmental risk but also the political will to address these inequalities and provide environmental justice as declared by the Member States in Parma.

Zsuzsanna Jakab WHO Regional Director for Europe

2 Commission on Social Determinants of Health (2008)� Closing the gap in a generation: health equity through action on the social determinants of health. Final report of the Commission on Social Determinants of Health� Geneva, World Health Organization (http://whqlibdoc�who�int/ publications/2008/9789241563703_eng�pdf, accessed 11 January 2012)�

3 WHO (2010)� Parma Declaration on Environment and Health. Copenhagen, WHO Regional Office for Europe (http://www.euro.who.int/ __data/assets/pdf_file/0011/78608/E93618.pdf, accessed 11 January 2012).

4 WHO (2011)� Rio Political Declaration on Social Determinants of Health� Geneva, World Health Organization (http://www�who�int/ sdhconference/declaration/Rio_political_declaration�pdf, accessed 11 January 2012)�

5 WHO (2009)� World Health Assembly resolution 62.14. Reducing health inequities through action on the social determinants of health� Geneva, World Health Organization (http://apps.who.int/gb/ebwha/pdf_files/A62/A62_R14-en.pdf, accessed 11 January 2012).

xiv

Environmental health inequalities in Europe xv

ExECuTIvE SummAry

THE CONCEPT OF ENvIrONmENTAl HEAlTH INEquAlITIES Environmental health inequalities refer to general differences in environmental health conditions. Socioeconomic and demographic inequalities in exposure to environmental hazards exist everywhere and can be expressed in relation to factors that may affect the risk of being exposed, such as income, education, employment, age, sex, race/ethnicity and specific locations or settings. In addition to these differences in exposure, environmental health inequalities are also caused by social or demographic differences in vulnerability towards certain risks.

Many of the environmental health inequalities, particularly where they are linked to socioeconomic variables or sex, also represent “inequities” because they are unfair, unjust and avoidable. The root cause of such inequalities is most often a lack of “distributive justice”, indicating that environmental risks are not evenly distributed within societies and populations, and a lack of “procedural justice”, indicating that different population groups may have different opportunities to influence decisions affecting their close environment.

rATIONAlE OF THE rEPOrT The objective of the report is to provide an initial baseline assessment of environmental health inequalities in the WHO European Region. It is based on available statistical data from national or international databases. To undertake the assessment, a set of 14 environmental health inequality indicators was developed, categorized into three inequality dimensions (see Table).

Table. Environmental health inequality indicators

Housing-related inequalities Injury-related inequalities Environment-related inequalities

• Inadequate water supply • Lack of a flush toilet • Lack of a bath or shower • Overcrowding • Dampness in the home • Inability to keep the home

adequately warm

• Work-related injuries • Fatal road traffic injuries • Fatal poisonings • Fatal falls

• Noise exposure at home • Lack of access to green/

recreational areas • Second-hand smoke exposure

at home • Second-hand smoke exposure

at work

For each environmental health inequality indicator, data from international databases were analysed to assess, by country or subregion, the existence and the magnitude of inequalities between different population subgroups.

National data were analysed for the development of national environmental health inequality fact sheets and practice examples (see Annexes 1 and 2). These national contributions indicate that more detailed assessments of environmental health inequality can be provided at national and subnational levels and that there are already national experiences with such assessments.

INEquAlITy ASSESSmENT FINdINGS The assessment of housing-, injury- and environment-related inequalities shows that inequalities exist throughout the WHO European Region. However, there are large differences between countries regarding the magnitude of the inequalities and the most affected population groups. Depending on

xvi Executive summary

the available data, inequality assessments were undertaken in relation to differences by sex, age, income, relative poverty, household type, social position, employment, occupation, education and difficulty paying bills. All of these sociodemographic determinants are found to be associated with significant inequalities. • Income and poverty-related inequalities are identified for noise exposure, exposure to second-hand

tobacco smoke at home and at work, and housing-related inequality indicators, where they are most clearly expressed. Compared to the other determinants applied, income- and poverty-related determinants display some of the strongest inequalities at subregional and national levels. Differences in national income levels are also associated with injury-related fatalities, with low/middle income countries reporting higher mortality rates.

• Sex-related inequality is most strongly associated with injury, where male fatality rates are often three times (and beyond) female fatality rates. Sex-related differences also appear in relation to second-hand tobacco smoke exposure, yet play no important role for housing-related risk factors.

• Age-related inequalities are present for injuries (especially falls) but differ in direction, depending on the indicator. Age impacts are less prominent for the other inequality indicators.

• Household type-related inequalities in housing conditions are especially identified for single-parent households, and increase when combined with low income and relative poverty factors.

• Data on inequalities by education, employment/occupation and self-assessed social position are only available for some of the environment-related inequalities, but they show a diverse inequality pattern: high education level is consistently associated with higher reported lack of access to recreational and green areas, while employment/occupation level shows different inequality patterns in exposure to second-hand smoke, with the direction of inequality depending on sex and subregion.

SuGGESTEd PrIOrITIES FOr NATIONAl ACTION Suggested priorities for national action are identified in the report, based on a combined assessment of the absolute magnitude of the respective environmental exposure for the whole population and the relative exposure differences between selected population subgroups. If the respective environmental health risk is greater in one country than in others, and if the distribution of the risk within the population is more unequal in that country than in others, the country thus identified should give priority to national follow-up activities in order to address these inequalities.

Suggested priorities for national action on inequalities are identified for 38 of the 53 countries of the WHO European Region and affect Member States from all subregions and developmental levels. However, of the 15 countries where no priority for national action on environmental health inequalities was identified, 12 countries only reported data for 5 or even fewer of the 30 assessed inequality dimensions covered within the 14 environmental health inequality indicators.

Annex 3 shows the suggested priorities for the individual countries of the WHO European Region. In countries with identified priorities for national action, a more detailed national assessment of the respective inequalities is needed in order to confirm and interpret them in the given national context. However, in countries where no data were available, this lack of information should, in and of itself, be a reason for more detailed investigation.

CONSTrAINTS ANd EvIdENCE GAPS The assessment report is affected by a range of constraints and gaps in evidence. The most significant constraints are (a) the lack of general data on environmental exposure in many countries, and (b) the limited opportunities for stratification of environmental exposure data by socioeconomic or demographic determinants. Further constraints relate to the quality and reliability of the data, and the lack of

Environmental health inequalities in Europe xvii

methodological consistency between national surveys, restricting the comparison of data collected in different countries. Priority steps to be taken towards the improvement of statistical evidence for environmental health inequality assessments would comprise: • establishment of surveys covering priority environmental health issues and specific target groups • increased use of social and demographic variables in environmental surveys • development of common tools, methods, definitions and criteria • better access to the available data.

CONCluSION The report conveys four key messages. • Environmental health inequalities exist in all subregions and in all countries, and are most often

suffered by disadvantaged population groups. • The magnitude of inequalities and the distribution of inequalities between advantaged and

disadvantaged population groups can be very diverse between countries and also depends on the socioeconomic or demographic variable used for stratification.

• To allow reliable identification of the most relevant target groups and to understand better the national inequality patterns and their causal mechanisms, more detailed environmental health inequality reporting and assessment are needed at the national level.

• The evidence base for the assessment of environmental health inequalities needs to be strengthened. This is valid for both data quantity (number of countries with data, number of risk factors reported) and data quality (reliability, opportunities for stratification).

Therefore, the results presented in this report provide an initial baseline assessment of selected environmental health inequalities in the WHO European Region. Further work is necessary to expand and further refine the assessment.

POSSIblE ACTIONS FOr TACKlING ENvIrONmENTAl HEAlTH INEquAlITIES Although national priorities and disadvantaged groups vary, action is necessary throughout the WHO European Region to reduce the observed inequalities. The report suggests six general recommendations for action, which can be tailored to the respective national situation: • action 1: general improvement of environmental conditions, assuring healthy environments for all; • action 2: mitigation and reduction of risk exposure in the most affected population groups, focusing

on the most exposed and/or most vulnerable subpopulations; • action 3: national environmental health inequality assessments to assess or confirm inequalities

based on national, more detailed data; • action 4: sharing experiences and case studies on successful interventions tackling environmental

health inequalities; • action 5: review and modification of national intersectoral policies in relation to environmental

health inequalities; • action 6: monitoring of environmental health inequalities using a standard set of inequality indicators.

INTRODUCTION

Introduction2

INTrOduCTION Matthias Braubach

“Decades of experience tell us that this world will not become a fair place for health all by itself.” (Margaret Chan, foreword to Blas and Sivasankara Kurup, 2010)

The Constitution of the World Health Organization, established in 1946, provides WHO with a mandate to strive for the highest possible level of health for all people, irrespective of their social status, ethnicity, sex or age (WHO, 1946). The 1978 Declaration of Alma-Ata confirms this priority, defining health as a fundamental human right and stating that “inequality in the health status of the people particularly between developed and developing countries as well as within countries is politically, socially and economically unacceptable and is, therefore, of common concern to all countries” (WHO, 1978). However, the Declaration of Alma-Ata also points out that action cannot rest within the health sector alone if the goal of attaining health for all is to be met, as health is achieved as a result of the policies and actions of many sectors. This is even more evident when looking at environmental health issues: because these issues are heavily influenced by the way we live, travel, work and consume, they cannot directly be affected or even mitigated by the health sector. Therefore, the provision of adequate and equal conditions – through environmental, social and infrastructural measures – is a task for all sectors and calls for intersectoral action (WHO, 2011a) and a “health in all policies” (HiAP) approach (Ministry of Social Affairs and Health, Finland, 2006).

rATIONAlE FOr HEAlTH INEquAlITy ASSESSmENT ANd mONITOrING The final report of the WHO Commission on Social Determinants of Health (CSDH), Closing the gap in a generation (CSDH, 2008), shows that inequalities in health are a major challenge for both development and overall progress in countries. The report provides strong evidence showing that the true causes of health inequalities reside in the social, economic and political environments shaping the conditions in which people live. These environments are affected by laws and regulations and can therefore be improved to ensure greater fairness and equality by developing new or modifying existing policies.

However, the way events unfold in reality can be quite different. Within almost all countries some groups of the population are at greater risk of experiencing harmful environmental conditions as a result of their sociodemographic circumstances. This environmental dimension of inequality and its multiple facets – known as environmental justice or environmental (in)equality – has in recent years been increasingly recognized and documented by both researchers and national governments.

There are significant sociodemographic inequalities in both exposure to and negative health outcomes arising from adverse environmental conditions. Such inequalities exist between countries, within countries and within communities and can devided into two categories – socioeconomic and demographic inequalities. Socioeconomic status (SES) variables such as income, employment, occupation and education are found to be especially strong determinants of environmental health risks. Demographic variables such as age, gender and ethnicity can modify the relationship between SES, environment and health, and can also directly affect exposure and health-related inequalities arising from biological, social, cultural and behavioural differences.

Environmental health inequalities in Europe 3

Calling on governments to close the gap in a generation, CSDH (2008) recommended three principles of action. • Improve daily living conditions. • Tackle the inequitable distribution of power, money and resources. • Measure and understand the problem and assess the impact of action.

The first recommendation is strongly related to the environmental conditions to which people are exposed on a daily basis. The third recommendation calls for assessment of the health situation in Member States in order to understand the problem, identify causal mechanisms and set priorities for action. Most importantly, it calls for monitoring of the impacts of actions and interventions. In the context of environmental health inequalities, various reporting and monitoring opportunities arise to connect environmental exposure data with sociodemographic information to describe the disparities of environmental risk within and between population groups.

In response to the CSDH final report, the World Health Assembly agreed in 2009 on a resolution to reduce health inequities through action on the social determinants of health (WHO, 2009a). This resolution provides WHO with a strong mandate to address the social determinants of health in its work, and urges Member States to: • tackle health inequities within as well as across countries; • develop mechanisms to integrate inequalities into public health actions; • consider inequity arguments in their policy-making.

The need for monitoring of and action on inequalities was confirmed by the World Conference on Social Determinants of Health held in Brazil in October 2011. The conference discussion paper (WHO, 2011b) indicates that a dearth of knowledge – resulting from an absence of inequality monitoring and of political accountability – is one of the main reasons for the lack of action and thus calls for increased reporting of inequalities using disaggregated data rather than information based on national averages.

ASSESSING ENvIrONmENTAl HEAlTH INEquAlITIES IN THE wHO EurOPEAN rEGION In 2009 the WHO Regional Office for Europe began to review the evidence on social and gender inequalities in environmental risk and exposure, drafting a policy brief and an evidence report on environmental inequalities, published at the Fifth Ministerial Conference on Environment and Health in 2010 (WHO, 2010a; 2010b). At the Conference Member States recognized environmental health inequalities as a priority for future work and adopted the Parma Declaration (WHO, 2010c), which provides WHO with a mandate to monitor the commitment of Member States to act on: • the health risks to children and other vulnerable population groups (with a specific focus on the

water and sanitation situation); • socioeconomic and gender inequalities in the human environment that are relevant for health.

Work undertaken by academic researchers, as well as by WHO and other international agencies, indicates that countries already have a significant ammount of information on the most vulnerable groups in relation to specific environmental threats. However, the respective data are often scattered and rarely brought together in a systematic way, as concluded by the first WHO expert meeting to review the evidence on environmental inequalities in 2009 (WHO, 2009b). Following up on this lack of quantitative evidence, and based on the Parma Declaration and the World Health Assembly resolution, WHO identified the need to assess in more detail the environmental health inequalities in the WHO European Region as a basis for further action by WHO and Member States.

Introduction4

rATIONAlE ANd OvErvIEw OF THE PrOjECT The main objective of the project was to assess and report on environmental health inequalities in the WHO European Region, based on available statistical data from national or international databases. The results of the project are presented in this assessment report, which describes the magnitude of environmental disparities in the WHO European Region and identifies the population groups that are most affected. Some academic research work referenced in the report chapters is also applied to put the statistical data into context, to provide information about the health relevance of the risk factors covered, and to shed light on inequalities that cannot be assessed through the data alone. However, emphasis is also placed on identifying and reporting the gaps in evidence that restrict the assessment of environmental inequalities, which may be as relevant for public health practitioners and policy-makers as the findings.

Initiated in 2010 and benefitting from the work reviewing academic evidence for the Fifth Ministerial Conference on Environment and Health, the project aimed to: • establish a list of environmental health risk factors for which data on socioeconomic or demographic

inequalities can be compiled at the national level; • select and apply an environmental health inequality indicator set for the assessment of country-

specific environmental health inequality data; • produce an assessment report on environmental health inequality together with national inequality

fact sheets.

Two milestone meetings took place at the WHO European Centre on Environment and Health in Bonn to mark the project’s progress.

Identification of available data and selection of inequality indicators Informed by the evidence review published for the Fifth Ministerial Conference on Environment and Health (WHO, 2010b), a compilation of available data on environmental health risk factors and their potential for stratification by sociodemographic determinants was put together during summer 2010. 17 Member States participated, searching for available data based on national censuses and surveys. In parallel, the WHO secretariat reviewed international databases (including those of the European Union (EU), the Organisation for Economic Co-operation and Development (OECD) and the United Nations) for data on the environmental health risk factors that could be stratified by socioeconomic or demographic determinants.

In October 2010 at the first project meeting 26 experts from different countries across the WHO European Region and WHO staff from various programmes reviewed and evaluated the compilation of environmental health inequality data and data sources (WHO, 2010d). From an initial 30 risk factors compiled by the WHO secretariat and the Member States, a set of 14 environmental health inequality indicators categorized into three inequality areas (housing-, injury- and environment-related inequalities) was agreed (see Table 1).

Although the review was undertaken on both the national and international levels, the meeting concluded that the data compiled through national surveys and censuses were too diverse to be used for international reporting. The main restrictions relate to the variety of collection methods and definitions used, which do not enable consistent and reliable comparison between countries (see Chapter 5 for details). Nevertheless, national data have strong potential to be useful in environmental health inequality assessments within individual countries, as indicated by the national inequality fact sheets and practice examples in Annexes 1 and 2.

Environmental health inequalities in Europe 5

Table 1. Environmental health inequality indicators

Indicator Sociodemographic stratification options available data source

Housing-related inequalities

Inadequate water supply Urbanization level WHO/UNICEF

Lack of a flush toilet Age, sex, income/poverty status and household type Eurostat

Lack of a bath or shower Age, sex, income/poverty status and household type Eurostat

Overcrowding Age, sex, income/poverty status and household type Eurostat

Dampness in the home Age, sex, income/poverty status and household type Eurostat

Inability to keep the home adequately warm Age, sex, income/poverty status and household type Eurostat

Injury-related inequalities

Work-related injuries Sex, age and occupation Eurostat

Fatal road traffic injuries Country income, age and sex WHO

Fatal poisonings Country income, age and sex WHO

Fatal falls Country income, age and sex WHO

Environment-related inequalities

Noise exposure at home Income/poverty status and household type Eurostat

Lack of access to green/recreational areas Age, sex, income, difficulty paying bills, employment, education level and household type

Eurofound

Second-hand smoke exposure at home Age, sex, self-assessed social position, difficulty paying bills and employment

Eurobaro meter

Second-hand smoke exposure at work Age, sex, self-assessed social position, difficulty paying bills and occupation

Eurobaro meter

Implementation of indicators and drafting the first assessment report Using the environmental health inequality indicators, subcontracted experts drafted reports assessing indicator-specific inequalities. Chapters on the concept of environmental health inequality and on the gaps in evidence identified as restricting a more detailed inequality assessment were developed in parallel. In addition, selected Member States were asked to provide fact sheets on environmental health inequalities (showing the potential for more detailed assessments using national data) and practice examples describing the experience and methods applied in recent national work identifying, monitoring and assessing environmental health inequalities.

At the second project meeting in June 2011, the chapter drafts, fact sheets and practice examples were peer-reviewed and discussed by 24 country representatives and experts. The chapters were then revised and finalized, based on their comments.

bENEFITS OF INEquAlITy ASSESSmENTS FOr ACTION Action to tackle inequalities needs to be informed by evidence on the population groups most affected and the sociodemographic features associated with the unequal distribution of risks and opportunities. Hence, better quality evidence and adequate identification of the specific target groups could help to make interventions more effective. Table 2 indicates the potential benefits of using inequality evidence for policy action, suggesting that such actions can be focused on societal structures and mechanisms as well as on resulting disparities in exposure and/or vulnerability.

Introduction6

Table 2. Benefits of inequality reporting for effective action on environmental health inequalities

Inequality evidence Policy actions

Evidence on societal structures and mechanisms leading to inequalities

• Provide examples of good/equitable societal practices� • Review and propose policy options on environmental protection� • Engage in public debate to incorporate health equity issues into economic and social

strategies and plans� • Support and implement equity-focused health impact assessment of policies and

infrastructural projects� Evidence on differential exposure to social and physical environmental risks

• Advocate for appropriate interventions to improve environmental conditions for the whole population�

• Target action on pollution hotspots and population groups with the highest exposures� • Influence the health ministry to shift attention upstream to policies that produce good

population health� • Support intersectoral action and extend HiAP approaches� • Actively participate in public education, regulation, infrastructure planning and design,

and taxation policy development affecting environmental conditions� Evidence on differential vulnerability to the risks

• Ensure adequate environmental and infrastructural services and conditions throughout each country�

• Increase targeted protection measures in areas or settings with a high density of vulnerable, sensitive or disproportionally affected populations�

• Improve environmental standards in the vicinity of child care centres, schools, hospitals, nursing homes, and similar�

Source: adapted and extended, based on a concept outlined in Blas, Sommerfeld and Sivasankara Kurup (2011).

Since the transformation of society structures and procedures may be more of a long-term objective for the improvement of health for all, the reduction of environmental inequalities specifically requires short- term interventions in decreasing exposure (Braubach et al., 2010). In this context, Table 2 indicates that in many cases the decision will be between two separate approaches: interventions assuring environmental conditions for all and targeted interventions tackling environmental conditions specific to certain groups or geographical units. Although both approaches are needed and can often be combined to achieve the best outcome (Dahlgren and Whitehead, 2006), the results of inequality assessments are essential to inform the decision-making process and provide guidance on the most appropriate way forward.

On the one hand, as indicated by the recent report on equity, social determinants and public health programmes (Blas and Sivasankara Kurup, 2010), the existence of linear gradients of environmental inequality (see Fig. 1, Country A) would strongly suggest that universal approaches – improving environmental conditions to reduce exposure for all groups, irrespective of social status – would be beneficial for the whole of society. Environmental actions such as assuring compliance with existing environmental standards throughout the country are likely to have the greatest benefits for the most disadvantaged segment of the population with the highest levels of exposure. Thus, broad-brush environmental actions might help to reduce inequalities more effectively.

On the other hand, actions should not ignore the specific needs of population groups with higher social disadvantage, which might benefit most from dedicated action. Thus, environmental inequality gradients with a skewed distribution (see Fig. 1, Country B) – especially those with excess risk for the poorest population groups – would benefit from the application of targeted actions focusing on the environmental conditions suffered by the most disadvantaged population groups, which, in addition, are often less socially included and less involved in political advocacy.

This assessment report provides examples that show how analysis based on the results of statistical data can assist with the selection of appropriate interventions. However, this approach requires the identification of gradients which cannot be produced when only dichotomous comparisons of, for example, “rich versus poor” and “male versus female” are possible. As demonstrated by the results in this report, data availability often does not facilitate adequate assessment of inequalities using these existing gradients.

Environmental health inequalities in Europe 7

Fig. 1. Examples of linear and nonlinear inequality gradients

1 (strong social disadvantage)

2 3 4 5 (no social disadvantage)

E xp

os ur

e pr

ev al

en ce

(% )

Country A Country B

OvErvIEw OF rEPOrT The assessment report begins with an introduction to the concept of environmental health inequalities (Chapter 1). It presents the historic development of the approach and provides insight into the terminology and scientific concepts used. This introduction will provide readers unfamiliar with the concept of environmental health inequality with a basic understanding of the field.

The conceptual introduction is followed by the three main chapters of the assessment report, presenting the environmental health inequalities in the WHO European Region. Chapter 2 looks at housing- related inequalities, covering those related to water and sanitation (water supply and sanitary equipment within homes) as well as those related to the quality and size of the dwelling (overcrowding, dampness and thermal comfort). This is followed by Chapter 3 on injury-related inequalities, which assesses the unequal distribution of work-related injuries and fatal traffic injuries, poisonings and falls. Chapter 4 then considers the inequalities in noise exposure, access to green and recreational areas, and second- hand smoke exposure at home and at work. Each of these assessment chapters also includes a section on the health relevance of the identified inequalities as well as main conclusions and suggested mitigation actions.

The presentation of the findings is complemented by a review of the evidence gaps and the barriers to assessing environmental health inequalities. Chapter 5 shows that the findings presented are far from exhaustive and argues that there are still fundamental gaps in the evidence yet to be tackled.

Chapter 6 then merges the findings to identify the patterns of and possible priority areas for action on environmental health inequality observed in the WHO European Region. The assessment results are reviewed to highlight: • the main inequalities found in the European subregions; • the countries facing the largest challenges of environmental health inequalities based on a

combination of the absolute magnitude of an environmental problem (prevalence levels or mortality rates in the total population) and the magnitude of relative inequality between selected population subgroups.

Finally, the report concludes by summarizing the most relevant key messages, and provides six recommendations for potential action.

Introduction8

Complementing and extending the international assessment report and its findings, three annex sections focus on evidence, experiences and suggested priorities for action at the national level. Annex 1 presents a national fact sheet for each of the 14 environmental health inequality indicators and shows that proper assessment of environmental health inequalities can be undertaken in all Member States of the WHO European Region, irrespective of social or economic level. Annex 2 provides specific examples and experiences from selected Member States, showing steps and methods that can be applied to identify and assess environmental health inequalities. Annex 3 presents in detail the assessment of suggested priorities for national action on range of environmental health inequality dimensions, as presented in Chapter 6.

mETHOdOlOGICAl NOTES As mentioned above, availability and consistency of data were the main challenges for putting together this assessment report. The variety of data formats and the available stratification options by sociodemographic determinants have also had an impact on the chapter contents. Table 1 above shows that for each of the three inequality dimensions (housing, injury and environment) different data sources were used for the assessment of environmental health inequalities. Rather than applying one common methodological approach to all indicators, the authors have tried to adapt the analysis to the available information by choosing the most practical analysis methods for the respective data. As a result, each chapter has approached the assessment and presentation of the inequality situation slightly differently. Chapter-specific sections on the data and methods used inform the reader about the information available for the assessment, the associated constraints, and the methods applied.

Nevertheless, throughout the assessment report, the authors have attempted to present two different inequality dimensions: • absolute dimensions of inequality, as shown by absolute differences in, for example, mortality rates

or environmental exposure prevalence levels between population groups; • relative dimensions of inequality (where appropriate), as shown by ratios comparing, for example,

the excess mortality in or prevalence of the most affected population group to the less affected or the total population, thus showing the relative magnitude of inequality.

While the authors believe that a complete assessment of environmental health inequalities must be based on both absolute and relative inequality dimensions, the data sometimes made this approach difficult in practical terms. Several examples shown in this assessment report indicate that the highest relative inequalities can often be found in countries where the overall prevalence of a given problem is very low. Therefore, it is necessary to note that any relative expression of inequality always needs to be interpreted in light of the overall prevalence situation, as well as the absolute differences between the compared population groups. For example, if the overall prevalence of an environmental problem in the general population is 1%, the lowest-income subgroups might have a prevalence of 5%, while the highest-income subgroups might have a prevalence of only 0.5%. The relative difference between these income groups is then described by a ratio of 10:1, while the absolute difference is 4.5%. In comparison, countries with an overall prevalence of 10% in the general population rarely achieve such high relative inequality ratios. It should also be noted that the same absolute difference of 4.5% provides a ratio of only 1.45:1 if the population groups compared have prevalence levels of 14.5% and 10%. Bearing this in mind, it is clear that in countries where both the prevalence of an environmental problem and the relative contrast in prevalence between subgroups are high, political action is more urgently required.

The sample sizes of the surveys used as data sources presented another constraint. Many of these surveys (such as those coordinated by Eurostat or Eurofound) are designed to provide nationally representative estimates for a range of variables for the total population of the country. However, when analysing such datasets from an inequality perspective, the data are divided into population subgroups, quickly reducing the respective sample size. For example, in the United Kingdom the sample size of households

Environmental health inequalities in Europe 9

participating in the Eurostat survey on EU Statistics on Income and Living Conditions (EU-SILC) is 7500. Analysing the effect, for example, of poverty (which may affect only 15% of the population) in single-parent households (which may be 5% of all households) reduces this sample size to only 50–60 households that represent single-parent households living in poverty. Similarly, the size of the respective sample is affected by the prevalence level of a given environmental problem, with lower prevalence levels reducing the sample size further. This makes the results less reliable and the findings less representative of the general population.

Another factor was the population size of the respective country: compared to the United Kingdom, which includes 7500 households in the EU-SILC survey, smaller countries such as Ireland and Estonia provide even smaller samples to start with (3750 and 3500 households respectively). Other surveys used, such as the Eurobarometer and European Quality of Life Survey (EQLS), are based on even lower sample sizes. Therefore, the assessment of environmental inequalities between population subgroups may suffer from poor reliability. Nevertheless, these databases seem to be the only sources providing consistent and comparable data for assessment of environmental health inequalities.

A further challenge was that many of the international databases are frequently updated. The main work on the assessment report was undertaken in 2011, all data having been downloaded in spring 2011. Final modifications and changes were made in late 2011 when data for 2010 started to become available for some (but not the majority of ) countries. Therefore, the inequality assessment is based on data reported for 2009 or, where this was not available, the last year of reporting for the respective countries. However, the lack of data for many countries, especially non-EU countries, is of much greater concern.

In order not only to compare countries but also to assess the inequality conditions by geopolitical subregion, the data were aggregated to reflect four subregions of the WHO European Region. Subregional categorization reflects the geographical and political situation as indicated by Table 3 and Map 1.5

Table 3. European subregions used for the assessment

Subregion Country coverage

Euro 1 (21 countries) All countries belonging to the EU before May 2004 and western European countries on comparable developmental level (such as Norway and Switzerland)

Euro 2 (12 countries) All countries joining the EU after May 2004 Euro 3 (12 countries) All countries belonging to the former Soviet Union (except the Baltic states) Euro 4 (8 countries) All countries in the south-east of the WHO European Region including the Balkans, Turkey

and Israel

Data from Eurostat, Eurobarometer and Eurofound, which cover only the EU countries and a few additional countries from the European Free Trade Association or EU candidate countries, use the subregional distinctions of “EU15” (for the 15 Member States belonging to the EU before May 2004) and “NMS12” (for the 12 Member States joining the EU after May 2004). Total figures for all EU Member States are labelled “EU27”.

For all figures and tables in this report, subregional terms such as “EU15” or “Euro 2”, for example, indicate that all the respective countries in these subregions are covered by the data. If data from one or more countries are missing, subregional terms “EU15 countries” or “Euro 2 countries” are used instead, indicating that the data are not based on all the countries within the respective subregion.

5 Euro 1: EU countries: Austria, Belgium, Denmark, Finland, France, Germany, Greece, Ireland, Italy, Luxembourg, Netherlands, Portugal, Spain, Sweden, United Kingdom� Non-EU countries: Andorra, Iceland, Monaco, Norway, San Marino, Switzerland� Euro 2: Bulgaria, Cyprus, Czech Republic, Estonia, Hungary, Latvia, Lithuania, Malta, Poland, Romania, Slovakia, Slovenia� Euro 3: Armenia, Azerbaijan, Belarus, Georgia, Kazakhstan, Kyrgyzstan, Republic of Moldova, Russian Federation, Tajikistan, Turkmenistan, Ukraine, Uzbekistan� Euro 4: Albania, Bosnia and Herzegovina, Croatia, Israel, Montenegro, Serbia, the former Yugoslav Republic of Macedonia, Turkey�

Introduction10

map 1. European subregions used for the assessment

Euro 1

Euro 2

Euro 3

Euro 4

The aggregation of data for the European subregions demonstrates another important restriction encountered during the assessment. Depending on the data source and the stratification of data, it was very difficult – and sometimes impossible – to derive accurate results for the subregions that would incorporate the population weight of the countries within the respective region. For many indicators, this would require a calculation of population subgroup sizes (by age group, sex, income, and so on) for each country to be used as a weighting factor in calculating the subregional average. In many cases – especially when combining several determinants – this proved impossible due to a lack of adequate data. As a result, the findings presented for the subregions often represent the arithmetic average of the national rates of the countries covered by the respective subregion, not adjusted for the different national population sizes. In each figure, this restriction is clearly marked as the average of national rates for all reporting countries of the subregion. Subregional data that are representative (often provided by Eurostat databases) do not include this indication.

dATA ACCESS Sources of data are listed in the reference section of each chapter. National data tables downloaded from these sources in spring 2011 can be requested by email from the WHO European Centre for Environment and Health. Please send your requests to info@ecehbonn.euro.who.int, marked “National EH inequality data tables”.

rEFErENCES

Blas E, Sivasankara Kurup A, eds. (2010). Equity, social determinants and public health programmes. Geneva, World Health Organization (http://whqlibdoc.who.int/publications/2010/9789241563970_eng.pdf, accessed 13 April 2011).

Blas E, Sommerfeld J, Sivasankara Kurup A, eds. (2011). Social determinants approaches to public health: from concept to practice. Geneva, World Health Organization (http://whqlibdoc.who.int/publications/2011/9789241564137_ eng.pdf, accessed 13 April 2011).

Braubach M et al. (2010). On the way to Parma: understanding and addressing the influence that social inequities have on environmental health. European Journal of Public Health 20(1):12–13.

CSDH (2008). Closing the gap in a generation: health equity through action on the social determinants of health. Final report of the Commission on Social Determinants of Health. Geneva, World Health Organization (http://whqlibdoc. who.int/publications/2008/9789241563703_eng.pdf, accessed 13 April 2011).

Environmental health inequalities in Europe 11

Dahlgren G, Whitehead M (2006). European strategies for tackling social inequities in health: levelling up, part 2. Copenhagen, WHO Regional Office for Europe (http://www.euro.who.int/__data/assets/pdf_file/0018/103824/ E89384.pdf, accessed 30 November 2011).

Ministry of Social Affairs and Health, Finland (2006). Health in all policies: prospects and potentials. Helsinki, Ministry of Social Affairs and Health (http://ec.europa.eu/health/archive/ph_information/documents/health_in_ all_policies.pdf, accessed 22 November 2011).

WHO (1946). Constitution of the World Health Organization. Geneva, World Health Organization (http:// whqlibdoc.who.int/hist/official_records/constitution.pdf, accessed 28 November 2011).

WHO (1978). Declaration of Alma-Ata. Geneva, World Health Organization (http://www.who.int/hpr/NPH/ docs/declaration_almaata.pdf, accessed 28 November 2011).

WHO (2009a). World Health Assembly Resolution WHA62.14. Reducing health inequities through action on the social determinants of health. Geneva, World Health Organization (http://apps.who.int/gb/ebwha/pdf_files/A62/A62_ R14-en.pdf, accessed 28 November 2011).

WHO (2009b). Environment and health risks: the influence and effects of social inequalities. Copenhagen, WHO Regional Office for Europe (http://www.euro.who.int/__data/assets/pdf_file/0020/115364/E93037.pdf, accessed 13 April 2011).

WHO (2010a). Social and gender inequalities in environment and health. Copenhagen, WHO Regional Office for Europe (http://www.euro.who.int/__data/assets/pdf_file/0010/76519/Parma_EH_Conf_pb1.pdf, accessed 13 April 2011).

WHO (2010b). Environment and health risks: a review of the influence and effects of social inequalities. Copenhagen, WHO Regional Office for Europe (http://www.euro.who.int/__data/assets/pdf_file/0003/78069/E93670.pdf , accessed 13 April 2011).

WHO (2010c). Parma Declaration on Environment and Health. Copenhagen, WHO Regional Office for Europe (http://www.euro.who.int/__data/assets/pdf_file/0011/78608/E93618.pdf, accessed 13 April 2011).

WHO (2010d). Towards environmental health inequality reporting. Report of an expert group meeting, Bonn, Germany, 25–26 October 2010. Copenhagen, WHO Regional Office for Europe (http://www.euro.who.int/__data/assets/ pdf_file/0013/130243/e94628.pdf, accessed 13 April 2011).

WHO (2011a). Rio Political Declaration on Social Determinants of Health. Geneva, World Health Organization (http://www.who.int/sdhconference/declaration/Rio_political_declaration.pdf, accessed 22 November 2011).

WHO (2011b). Closing the gap: policy into practice on social determinants of health: discussion paper. Geneva, World Health Organization (http://www.who.int/sdhconference/Discussion-Paper-EN.pdf, accessed 22 November 2011).

THE CONCEPT OF ENVIRONMENTAL

HEALTH INEQUALITIES

CHAPTER

Chapter 1. The concept of environmental health inequalities14

CHAPTEr 1. THE CONCEPT OF ENvIrONmENTAl HEAlTH INEquAlITIES George Morris, Matthias Braubach

A HISTOrIC PErSPECTIvE While priorities and emphases change over time and according to location, the environmental health approach has traditionally centred on protection of population health through identifying, monitoring and controlling the environmental hazards which produce disease in populations. The approach has its origins in the earliest days of the modern public health movement and, by assuring the quality of domestic, community and occupational environments, has greatly extended lifespans and improved health and well-being for communities and individuals. Underpinned by advances in epidemiology and the biological understanding of disease, the disease-centred, hazard-focused approach to environmental health remains a cornerstone of public health activity.

It was clear even to the 19th-century public health pioneers that the degraded, malodorous neighbourhoods where lives were shortest and most blighted by disease were also home to the poorest communities. Recognition of the importance of environmental conditions for population health has always been, and continues to be, accompanied by recognition of the interplay between sociodemographic and physical factors in producing inequalities in health and well-being. The final report of the CSDH, Closing the gap in a generation (CSDH, 2008), reinforces the global relevance of this interplay for the 21st century. Notably, the first of the report’s three principles of action to tackle social inequity in health is: “improve the conditions of daily life – the circumstances in which people are born, grow, live, work, and age”. The report is suffused with references to the alignment of, and interplay between, sociodemographic, economic and physical factors in ways which bear on health and equity. This reinforces the fact that the physical environment – alongside the social environment and genetic endowment – is one key driver in the creation and destruction of health and well-being, and thus also a main driver for health inequalities.

In summary, in the 150 years and more during which there has been tangible interest in population health and action at the level of society to protect and improve it, inequalities in health between different social groups have been an abiding public health challenge. As the second decade of the 21st century begins, it could be argued that remarkable health gains delivered by adherence to a population focus are increasingly overshadowed by persisting and increasing variability between and within countries. Implicitly, the notable achievements of public health are not enjoyed by all. By extension, and despite a sometimes diminished political profile, differences in the physical context for people’s lives – referred to as environmental justice issues or environmental health inequalities – remain central to the health inequalities challenge throughout the world.

Acutely aware of this issue, ministers and representatives of Member States of the WHO European Region came together in 2010 at the Fifth Ministerial Conference on Environment and Health in Parma, Italy, to chart the next steps in the European environment and health process and, in the words of the Parma Declaration, “to face the key environment and health challenges of our time” (WHO, 2010).

Environmental health inequalities in Europe 15

Listed among the key environment and health challenges on which they made a commitment to act were: “the health risks to children and other vulnerable groups posed by poor environmental, working and living conditions (especially the lack of water and sanitation)” and “socioeconomic and gender inequalities in the human environment and health”. Each of these reflects recognition at a political level of the interplay between social and environmental variables and the need to tackle each to create better and more equal health for all. Evidence providers in the scientific, medical and epidemiological communities also recognize shared agendas and methodological challenges and the need to work in partnership. There is, for example, both conceptual and methodological overlap between the activities of environmental epidemiologists who study the effects of environmental exposures on health and disease in the population and social epidemiologists who often use social concepts to better understand and explain patterns of health in the population.

Key message 1 Sociodemographic inequalities in the exposure to environmental hazards exist everywhere and they are not new. These inequalities can be expressed in relation to factors such as income, education, employment, age, gender, race/ethnicity and specific locations or settings.

INEquAlITy ANd INEquITy Notions of fairness versus unfairness and justice versus injustice now inform the language of public health when speaking about health differences between population subgroups. Like any type of inequality, inequalities in health and its determinants between different groups of people may, on one level, be regarded as natural and inevitable. An example might be differences in a range of health outcomes observed between different demographic groups, such as the elderly versus the rest of the population. However, normally, when health inequalities are observed between socially defined groups, they are more accurately described as “health inequities”. This term is now widely used to denote situations in which the distribution of health and its determinants is not simply unequal, but also unjust, unfair and avoidable (WHO, 2011).

Viewed from an environmental health perspective, the differential exposure of groups of people to health-relevant aspects of environment (with potential to create and sustain differences in health status) can often simply be inequalities. This might be the case where a group of people chooses to live in a polluted city centre for reasons of convenience or chooses riverside homes – potentially more liable to flooding – for aesthetic reasons or social status. However, the potential for differences in health outcome linked to environment may have little or nothing to do with choice or biological variation and may have its origin in factors beyond the influence of those affected. Here the environmental health challenge is about addressing health inequities that are unfair and avoidable.

Key message 2 The term “health inequalities” refers to general differences in health. Many of these differences (particularly where they are linked to social variables or gender) represent “health inequities” because they are unfair, unjust and avoidable.

IdENTIFICATION ANd ASSESSmENT OF INEquAlITIES ANd INEquITIES To identify, assess, monitor and ultimately address environmental health inequalities and inequities associated with sociodemographic determinants, it is necessary to develop appropriate measures of environmental quality; this includes health-promoting aspects of environment in relation to social or demographic variables such as income, education, employment, age, gender, race/ethnicity and

Chapter 1. The concept of environmental health inequalities16

specific locations or settings. In practice, this creates a requirement for robust indicators to illustrate the relationship between environmental health risk and different sociodemographic variables and permit better understanding regarding specific risk groups and their exposure. Such indicators might be termed “indicators of environmental health inequality”. Thus, the concentration of, for example, particulate matter in different areas might be related to the income of people living there to create an indicator of environmental health inequality. The potential to use such indicators to better understand public health problems and to shape and evaluate the policy response is considerable. They permit an assessment and analysis of the social distribution of exposure and impacts and allow comparison within and between nations which, when used constructively, can benefit all concerned. When used to assess environmental health inequality within nations, such inequality indicators can tease out problems which might otherwise be masked by average figures. Clearly, the importance a country attaches to delivering better life circumstances for its most disadvantaged groups, and its success in doing so, can be considered a telling indicator of its political, social and economic development. This reinforces the value of indicators of environmental health inequality in a broad context.

Nevertheless, indicators have no practical value unless they can be used to gather and process information about environmental health inequalities in practice, and this demands data. In many locations the data are simply absent, perhaps due to a lack of political will or resources to create the systems and structures for data generation. This may, of itself, be an inequality.

Key message 3 Robust indicators of environmental health inequality that combine both social and environmental factors are needed, allowing these inequalities to be identified, assessed and tackled.

ENvIrONmENTAl HEAlTH INEquAlITy: HAzArd ANd rISK Environmental health inequalities can result in many ways: a typical mechanism is when areas populated by particular social groups have a greater concentration of environmental hazards and a scarcity or absence of environmental “goods”. This will almost inevitably disadvantage or marginalize population subgroups with certain characteristics in relation to, for example, gender, ethnic origin, occupation, income level, urban versus rural location, and so on. This unequal distribution between social groups is frequently described as an absence of “environmental justice” (Bullard, 2008; Curtice et al., 2005). However, the “distributive” element of environmental justice (which is about achieving more equal distribution of hazards and goods between population groups) is inextricably bound up with a need to ensure that different groups have equal capacity to influence decisions about what is and is not situated in their area. This second component of environmental justice is often termed “procedural justice” and a lack of procedural justice, in addition to the lack of distributive justice, often characterizes sociodemographically disadvantaged groups.

However, a comprehensive consideration of the role of sociodemographic factors in environmental health inequality must look above and beyond individual components of environmental justice to consider how a range of sociodemographic variables can modify not only the presence or absence of environmental hazards but also the individual risk of exposure and associated health consequences. Looking more closely at the influence of sociodemographic factors on environmental risk for the individual, it can readily be appreciated that factors such as age, gender, SES and indeed culture may have quite a profound influence on whether an individual chooses to be physically active or not, or to behave in a way which results in higher or lower exposure to a hazardous aspect of environment. There is a need to recognize that where sociodemographic factors influence individual opportunity, empowerment and dignity, they may critically influence an individual’s decision, for example, to be physically active or avoid harmful exposures. It is evident that there is a socially-mediated mechanism that affects the individual risk exposure. In any case, all dimensions of environmental health inequality are of equivalent policy relevance.

Environmental health inequalities in Europe 17

Key message 4 There are sociodemographically determined inequalities in population-level environmental hazard but, because sociodemographic factors may also modify individual exposure and the health impact for the same degree of exposure, there may also be sociodemographically determined inequalities in individual environmental health risk. Each level needs to be identified and assessed.

SOCIOdEmOGrAPHIC FACTOrS, ExPOSurE ANd vulNErAbIlITy As described above, inequalities in environmental conditions and the lack of distributive justice regarding the location of environmental hazards lead to a greater probability of exposure to environmental health threats. Indeed, a wide range of surveys have shown that marginalized and disadvantaged groups – irrespective of the type of disadvantage, which can be education- or income-related as well as gender- specific or associated with ethnicity – are most often characterized as having the highest levels of exposure to environmental problems.

It is further recognized that the same degree of environmental exposure can result in a greater health impact when borne by a disadvantaged population; this may be due to a lower ability to respond to the environmental stress, perhaps exacerbated by other health pressures leading to synergistic effects. For example, sociodemographic and other factors can influence whether, having been exposed to a health- determining environmental factor, an individual goes on to experience a particular health outcome, and to what extent (the “exposure–response function”). The capacity for age, gender, genetic inheritance, pre-existing illness or psychosocial stress – singly or in joint interaction – to influence the exposure– response function is well understood in many cases.

Key message 5 Sociodemographic inequalities can be caused by differences in exposure to environmental risks (exposure differential), as well as by social or demographic differences in vulnerability towards certain risks (vulnerability differential).

THE PSyCHOSOCIAl dImENSION IN ENvIrONmENTAl HEAlTH INEquAlITy In recent times, observation of and scientific interest in the vulnerability differential between different sociodemographic groups have led researchers to consider the role played by psychosocial stress. Psychosocial stress may have a number of origins but may be directly linked to social and physical characteristics of the places where people live. It is increasingly seen as a key factor in determining individual vulnerability to environmental hazards (Gee, Payne-Sturges, 2004). Psychosocial stress produces acute and chronic changes in the functioning of body systems such as those governing immune and inflammatory response, leading directly to illness or perhaps rendering individuals more vulnerable when exposed to, for example, a toxic environment. This may be particularly important in the absence of any counterbalancing effect from positive life circumstances and resources. Reflecting on the significant health inequalities challenge in Scotland and on the role of the physical environment, Scotland’s Chief Medical Officer emphasized the importance of the psychosocial dimension when he observed that “how people feel about their physical surroundings, can impact on not just mental health and well- being, but also physical disease” (Scottish Government, 2007).

Key message 6 People’s perceptions of the physical aspects of the places they live in can profoundly impact on their mental and physical health and their longevity.

Chapter 1. The concept of environmental health inequalities18

FrAmING THE PrOblEm During the meeting of an expert group on environmental health inequalities held in Bonn in September 2009 (WHO, 2009), attendees discussed a WHO contextual framework (see Fig. 2) which seeks to structure and identify potential pathways through which sociodemographic variables influence: • the nature and distribution of environmental conditions; • the exposure to these conditions for individuals and groups within society; • the exposure–response relationships which lead to different health outcomes in individuals with

comparable exposures; • access to, and quality of, health-related services.

The framework offers a useful, holistic approach to framing issues in

Informations clés

Organisation Organisation mondiale de la santé (OMS)

Type de document Publications

Date d'adoption 1 janvier 2012

Source Organisation mondiale de la santé