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

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

The use of general descriptive names, trade names, trademarks, etc. in a publication, even if not specifically
identified, does not imply that these names are not protected by the relevant laws and regulations.
The designations employed and the presentation of the material in this publication do not imply the expression
of any opinion whatsoever on the part of the Secretariat of the World Health Organization concerning the
legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its fron-
tiers or boundaries.
The views expressed in this publication are those of the contributors and do not necessarily represent the deci-
sions or the stated policy of the World Health Organization.
The Federal Minister for the Environment, Nature Conversation and Nuclear Safety (Federal Republic of Ger-
many) provided financial support for, and undertook the printing of, this publication.
Die Deutsche Bibliothek – CIP-Einheitsaufnahme
Concern for Europe’s tomorrow : health and the environment
in the WHO European region / WHO European Centre for
Environment and Health. [Publ. on behalf of the World Health
Organization Regional Office for Europe]. – Stuttgart : Wiss.
Verl Ges., 1995
ISBN 3–8047–1406–4
NE: European Centre for Environment and Health
© World Health Organization 1995
Published on behalf of the World Health Organization Regional Office for Europe by Wissenschaftliche Ver-
lagsgesellschaft mbH
All rights reserved.
No part of this book may be reproduced, stored in a retrieval system, or transmitted in any form or by any
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Printed in Germany
5
Foreword
The remarkable political changes that have
taken place within the European Region in
the last five years have greatly enlarged the
potential for international collaboration. The
First European Conference on Environment
and Health was held in Frankfurt in De-
cember 1989, when these dramatic changes
were at their height. Ministers from 29 coun-
tries, and the European Commission, ap-
proved a Charter that set out the principles,
strategy and priorities for achieving an effec-
tive approach to the many areas in which en-
vironmental conditions may significantly af-
fect human health.
The Charter reflected the ministers’ con-
cern that the nature and extent of environ-
mental health problems throughout the Re-
gion had not been adequately assessed. The
WHO European Centre for Environment
and Health, which was established as a di-
rect result of the Conference’s recommen-
dations, was therefore given as its first major
task the development of a comprehensive re-
view of available data in such fields as water
supply and sanitation, air and water pollu-
tion, radiation protection, food safety, occu-
pational health, and housing and settle-

ments. The project was entitled Concern for
Europe’s Tomorrow, and the Scientific Ad-
visory Board of the European Centre de-
cided that the final report should be avail-
able as the scientific basis for deliberations
at the Second European Conference on En-
vironment and Health in Helsinki in June
1994.
The time available for preparation was ex-
tremely limited. The fact that a summary of
the final report was available in time for the
Second European Conference reflects great
credit on the many scientists (more than
270) and officially established national focal
points in the Member States who have taken
part in this major undertaking.
The report highlights a number of issues
that demand urgent attention and has con-
firmed the existence of major differences in
environmental conditions and the health
status of populations between the western
countries of the Region and the countries of
central and eastern Europe and the newly in-
dependent states of the former USSR.
None of the countries of our Region, how-
ever, has room for complacency. As one
example, substantial areas of many Euro-
pean cities provide a deteriorating environ-
ment for their citizens, owing to traffic
noise, pollution and congestion, and social

deprivation. Clearly, not all issues are of
equal importance and it is hoped that the ob-
jective scientific nature of this report will
help to allay unjustified public fears and to
provide a more realistic perception of risk.
Above all, the report is intended to be of as-
sistance in rational decision-making, so that
real priorities may be identified and limited
resources efficiently utilized.
The process of developing this report has
demonstrated the shortcomings of the avail-
able data, in both coverage and consistency.
Nevertheless, the report is a major step for-
ward. I am confident that the network of
national focal points, which has now been
firmly established, and the close collabor-
ation between the WHO Regional Office for
Europe and other international organiz-
ations, in particular the European Environ-
ment Agency, provide excellent prospects for
considerable improvements in the quantity
6 Foreword
and quality of available information between
now and the Third European Conference
planned for 1999.
The present volume, which has been devel-
oped in very close cooperation with the Eu-
rope’s Environment Task Force of the Euro-
pean Commission, represents a major step
forward in collaboration among all 50 coun-

tries of the WHO European Region. It is
hoped that it will be widely used, not only by
government agencies but also by the very
many nongovernmental organizations deal-
ing with different aspects of the issues ad-
dressed by Concern for Europe’s Tomorrow.
J.E. Asvall
WHO Regional Director for Europe
7
Table of Contents
Foreword
Acknowledgements
Contributors
5
17
17
Introduction
Part I
Background
1 Economic Sectors
Th
e
S
ett
i
ng
23
The Genesis of Concern for
Europe’s Tomorrow
24

The Development of Concern for
Europe’s Tomorrow
26
The Scope and Purpose of Concern
for Europe’s Tomorrow
27
Li
m
i
tat
i
ons an
dC
onstra
i
nts
28
Beyond Concern for Europe’s
Tomorrow
28
References
29
1
.
1I
ntro
d
uct
i
on

33
1.2 The WHO European
Region
33
1.2.1 Basic features and
indicators
33
1.2.2 Development of economic
activities
36
1.2.3 The CCEE and NIS
36
1.3 An Outlook for the Future
39
1.3.1 Some trends
39
1.3.2 Some scenarios
40
1.4 Energy
40
1.4.1 Indicators and trends
41
1
.
5I
n
d
ustry
48
1.5.1 Indicators and trends 48

1.6 Agriculture
51
1.6.1 Indicators and trends
53
1.7 Transport
54
1.7.1 Indicators and trends
54
1.8 Tourism
56
1.8.1 Indicators and trends
56
1.9 Urban Development
58
1.9.1 Indicators and trends
59
1.10 Conclusions
60
References
61
8 Table of Contents
2 Environmental Health Management
3 Economics, the Environment and Health
4 State of Human Health
2
.
1I
ntro
d
uct

i
on
63
2.2 Environmental Health
Services
64
2.3 Intersectorality
65
2.4 Involvement at the Local
and Regional Levels
66
2
.
5I
ntervent
i
on an
dC
ontro
l 69
2.6 Public Participation 70
2.7 Environmental Health
Professionals
72
2.8 Conclusions
73
References
73
3
.

1I
ntro
d
uct
i
on
75
3.1.1 Links 75
3.1.2 Environmental epidemi-
ology and environmental
health economics
76
3.2 The Productive Economy
and the Environment
76
3.2.1 Response of industry to
environmental concerns
77
3.3 Investment in Environment
and Health
78
3.4 Failure of Economic
Systems
81
3
.
5I
ssues
f
or t

h
e
CCEE
and NIS 81
3.6 Funding and Management
of Environmental
Improvement
83
3.7 Economic Instruments
84
3.8 Information
85
3.9 Conclusions
87
3.9.1 Economic strategy
87
3.9.2 Information
88
References
88
4
.
1I
ntro
d
uct
i
on
90
4.2 Demographic, Socioeco-

nomic and Lifestyle Data
91
4.2.1 Population size and
age structure
91
4.2.2 Population distribution
92
4.2.3 Socioeconomic factors
92
4.2.4 Lifestyle indicators
93
4.3 Availability and Interpreta-
tion of Health Data
93
4.4 Infant Mortality
96
4.5 Life Expectancy and Total
Mortality
98
4.5.1 Life expectancy
98
4
.
5
.
2 All
causes o
f
morta
li

ty
101
4.5.3 Spatial patterns at the
subnational level
102
4.6 Occurrence of Selected
Diseases
103
4.6.1 Structure of total mortality
by cause
103
4.6.2 Selected groups of
diseases
103
4.7 Inequalities in Health
Status
122
4.8 Conclusions
124
References
125
Table of Contents 9
Part II
Environmental Exposure
5 Air Pollution
6 Water Supply and Quality
5.
1
Intro
d

uction
139
5.2 Potential Health Effects 140
5.2.1 Sulfur dioxide and suspend-
ed particulate matter
141
5.2.2 Lead
144
5.2.3 Nitrogen dioxide
144
5.2.4 Ozone
145
5.3 Ambient Air Pollution and
Exposure Assessment
146
5.3.1 Methodology
146
5.3.2 Sulfur dioxide
147
5.3.3 Suspended particulate
matter
151
5.3.4 Lead
153
5.3.5 Nitrogen dioxide
155
5.3.6 Ozone
157
5.4 Indoor Air Pollution
160

5.4.1 Pollutants and their
sources
160
5.
4
.
2
E
ff
ects on
h
ea
l
t
h 161
5.4.3 Exposure in Europe 164
5.5 Global and Transboundary
Air Pollution
165
5.5.1 Climate change in the
European Region
166
5.5.2 Ozone depletion in the
European Region
167
5.5.3 Acid deposition in the
European Region
167
5.6 Trends
168

5.6.1 Ambient air
168
5.6.2 Indoor air
170
5.6.3 Problems in exposure and
health risk assessment
170
5.6.4 Global and transboundary
air pollution
171
5.7 Conclusions
171
References
172
6
.
1H
ea
l
t
hEff
ects
176
6.1.1 Guidelines and standards
for drinking-water
177
6.1.2 Microbial contaminants
178
6.1.3 Chemical contaminants
179

6.2 Exposure
184
6.2.1 Exposure to microbial
contamination
184
6.2.2 Exposure to chemical
contamination
187
6.2.3 Water supply coverage and
shortages
191
6.3 Causes of Exposure to
Waterborne Hazards
194
6
.
3
.
1I
na
d
equate raw water qua
li
ty
and quantity
195
6.3.2 Inadequate treatment and
distribution
196
6.4 Trends

196
6.4.1 Demands for surface water
and groundwater
196
6.4.2 Quality
197
6.4.3 Sources of pollution
198
6.4.4 Technical and infra-
structure needs
198
6.4.5 Management and control
199
6.5 Conclusions
199
References
201
10 Table of Contents
7 Wastewater and Surface Water
8 Solid Waste
9 Contamination of Food and Drink
7
.
1H
ea
l
t
hEff
ects
203

7.1.1 Direct contact with surface
water through bathing
204
7.1.2 Direct occupational contact
with wastewater
205
7.1.3 Aerosols
205
7.1.4 Smells
205
7.1.5 Wastewater irrigation
206
7.2 Exposure
207
7.2.1 Populations with inadequate
sewage disposal or
wastewater treatment
facilities
207
7.2.2 Exposure through
recreational use
210
7
.
2
.
3P
ro
d
uct

i
on an
d
consump-
tion of raw foods irrigated
with water of insufficient
quality
212
7.3 Causes of Pollution
214
7.3.1 Wastewater
214
7.3.2 Pollution from non-point
sources
215
7.4 Trends
216
7.4.1 Improvements in networks
and treatment
216
7.4.2 Reduction of pollution
217
7.4.3 Monitoring
218
7.4.4 Management
218
7.5 Conclusions
219
References
220

8
.
1I
ntro
d
uct
i
on
222
8.1.1 Definitions 222
8.2 Waste Production
223
8.2.1 Municipal waste
223
8.2.2 Industrial waste
225
8.2.3 Mining waste
226
8.2.4 Small-quantity hazardous
waste
227
8.2.5 Health care waste
227
8.3 Waste Management
227
8.3.1 Collection
227
8.3.2 Disposal
228
8.3.3 Recovery, recycling and

prevention
230
8.4 Contaminated Sites
230
8
.
5T
rans
f
ront
i
er
M
ovement
of Waste
231
8.6 Waste Management and
Health Effects
232
8.6.1 Methodological problems
232
8.6.2 Sanitary landfills
232
8.6.3 Incineration
233
8.6.4 Application of sewage
sludges and compost to
land
235
8.7 Occupational Exposure to

Waste Substances
235
8.8 Trends
237
8.9 Conclusions
237
References
238
9
.
1I
ntro
d
uct
i
on
241
9.2 Food Safety Regulations,
Services and Information
Systems
242
9.2.1 Current situation
242
9
.
2
.
2F
oo
d

sa
f
ety structure
242
9.3 Microbiological Con-
tamination
243
9.3.1 Current situation
244
9.3.2 Control measures
247
Table of Contents 11
10 Multimedia Exposure to Selected Chemicals
9
.
3
.
3F
oo
db
orne
di
seases
d
ue to
microorganisms
249
9.4 Chemical Contamination
253
9.4.1 Current situation

254
9.4.2 Exposure to chemical
contaminants
258
9.4.3 Evaluation of food contami-
nation factors as indicated
by national focal points
263
9.5 Radioactive Contamination
264
9.5.1 Natural radionuclides
264
9.5.2 Weapons fallout
265
9.5.3 Chernobyl
266
9.5.4 Radiation dose
268
9.5.5 Risk
268
9.6 Safety of Food Produced
by Biotechnology
268
9.6.1 Fermented foods
269
9.6.2 Genetic modification
269
9.6.3 Implications of
biotechnology
269

9
.
7D
ata
Q
ua
li
ty an
d
Comparability 269
9.7.1 National differences in the
collection of information
and data
270
9.7.2 Comparability of national
data on outbreaks
270
9.8 Conclusions
271
9.8.1 Food safety regulations and
information systems
271
9.8.2 Microbiological contamina-
tion of food and related
foodborne diseases
272
9.8.3 Chemical contamination of
food and drink
272
9.8.4 Radioactive contamination

of food
273
9.8.5 Biotechnologically pro-
duced foods and drinks
273
References
273
10
.
1I
ntro
d
uct
i
on
278
10.2 Arsenic 280
10.2.1 Toxic and carcinogenic
effects
280
10.2.2 Exposure
280
10.2.3 Tissue levels
281
10.2.4 Evaluation of observed
exposure levels and possible
health effects
281
10.3 Cadmium
282

10.3.1 Toxic and carcinogenic
effects
282
10.3.2 Exposure
282
10.3.3 Tissue levels
283
10.3.4 Evaluation of observed
exposure levels and possible
health effects
284
10.4 Lead
285
10.4.1 Toxic and carcinogenic
effects
285
10.4.2 Exposure
286
10.4.3 Tissue levels
286
10
.
4
.
4E
va
l
uat
i
on o

f
o
b
serve
d
exposure levels and possible
health effects
287
10.5 Mercury
288
10.5.1 Toxic and carcinogenic
effects
289
10.5.2 Exposure
290
10.5.3 Tissue levels
290
10.5.4 Evaluation of observed
exposure levels and possible
health effects
291
10.6 Pesticides
292
10.6.1 Toxic and carcinogenic
effects
292
10.6.2 Exposure
295
10.6.3 Tissue levels
296

10.6.4 Evaluation of observed
exposure levels and possible
health effects
298
10.7 Nitrate
298
10.7.1 Toxic and carcinogenic
effects
298
12 Table of Contents
11 Nonionizing Radiation
12 Ionizing Radiation
10
.
7
.
2E
xposure
298
10.7.3 Tissue levels 299
10.7.4 Evaluation of observed
exposure levels and possible
health effects
299
10.8 Benzene
299
10.8.1 Toxic and carcinogenic
effects
300
10.8.2 Exposure

300
10.8.3 Tissue levels
300
10.8.4 Evaluation of observed
exposure levels and possible
health effects
301
10.9 Polynuclear Aromatic
Hydrocarbons
301
10.9.1 Toxic and carcinogenic
effects
301
10.9.2 Exposure
301
10.9.3 Tissue levels
302
10.9.4 Evaluation of observed
exposure levels and possible
health effects
302
10
.
10 P
o
l
yc
hl
or
i

nate
dBi
p
h
eny
l
s
303
10.10.1 Toxic and carcinogenic
effects
303
10.10.2 Exposure
304
10.10.3 Tissue levels
304
10.10.4 Evaluation of observed
exposure levels and possible
health effects
306
10.11 Polychlorinated Dibenzo-
p-Dioxins and Dibenzo-
furans
307
10.11.1 Toxic and carcinogenic
effects
307
10.11.2 Exposure
308
10.11.3 Tissue levels
309

10.11.4 Evaluation of observed
exposure levels and possible
health effects
309
10.12 Conclusions
310
References
311
11
.
1I
ntro
d
uct
i
on
315
11.2 Ultraviolet Radiation 316
11.2.1 Solar radiation
316
11.2.2 Artificial sources of
UV radiation
318
11.2.3 Biological effects
319
11.2.4 Effects on health
320
11.2.5 Effects on the ecosystem
323
11.2.6 Conclusions

323
11
.
3El
ectr
i
can
dM
agnet
i
c
Fields
324
11.3.1 Interaction mechanisms
325
11.3.2 Biological effects
326
11.3.3 Epidemiological studies
328
11.3.4 Exposure limits and
protective measures
329
11.3.5 Conclusions
331
References
331
12
.
1S
ources

334
12.2 Biological Effects 336
12.2.1 Nature and quality of
ionizing radiation
336
12.2.2 Effects on health
336
12.2.3 Assessment of risk
337
12.3 Control of Exposure
337
12.3.1 Converting exposure to
dose
337
12
.
3
.
2Al
p
h
aem
i
tters
337
12.3.3 Recommendations on
radiation protection
339
12.4 Priorities in Environmental
Exposure

339
12.4.1 Radiation accidents
339
12.4.2 Safety of nuclear power
plants
344
12.4.3 Weapons testing
345
Table of Contents 13
13 Residential Noise
14 Housing and the Indoor and Urban Environments
15 Occupational Health
12
.
4
.
4Di
sposa
l
o
f
ra
di
oact
i
ve
waste
345
12.4.5 Radon
347

12
.
4
.
6O
ccupat
i
ona
l
exposure
349
12.5 Conclusions 351
References
351
13
.
1Wh
at
i
s
R
es
id
ent
i
a
lN
o
i
se

? 353
13.2 Magnitude of Problems 354
13.3 Annoyance
356
13.3.1 Disturbance of sleep
357
13.3.2 Communication
disturbances
359
13.3.3 Stress and fatigue
360
13.4 Effects on Health
360
13.5 Economic and Other
Consequences
360
13
.
5
.
1D
eprec
i
at
i
on
360
13.5.2 Complaints 361
13.6 Regulations
362

13.7 Conclusions
364
13.7.1 Land-use planning
364
13.7.2 Health studies on exposed
populations
364
13.7.3 Concern for the future
364
References
365
14
.
1I
ntro
d
uct
i
on
367
14.1.1 Interaction of housing,
other conditions and
health status
367
14.1.2 Housing factors affecting
health
368
14.1.3 Current housing and health
issues in the European
Region

368
14.1.4 European health for all
targets related to housing
369
14.1.5 Urbanization
370
14.1.6 Current problems in Euro-
pean urban development
370
14.1.7 Housing policies
372
14.2 Studying Housing and
Health
373
14
.
2
.
1S
ources o
fi
n
f
ormat
i
on:
housing
373
14.2.2 Sources of information:
housing-related health

status
374
14.2.3 Housing stock
375
14.2.4 Space
376
14.2.5 Hygiene
377
14.2.6 Indoor air quality
379
14.2.7 Indoor climate
381
14.2.8 Groups with special needs
382
14.2.9 Accidents in the home
384
14.3 Trends
387
14.3.1 Urbanization
387
14.3.2 Homelessness
387
14.3.3 Accidents
387
14.4 Conclusions
388
References
388
15
.

1C
urrent
T
ren
d
s
i
n
E
uropean
Working Life
390
15.2 Important Factors at Work
and in the Work Environ-
ment
392
15
.
2
.
1M
ec
h
an
i
ca
l
r
i
s

kf
actors
393
15.2.2 Workload and ergonomic
conditions
397
15.2.3 Physical factors
398
15.2.4 Chemical hazards
400
14 Table of Contents
16 Accidents and Man-made Disasters
17 Environmental Health in the CCEE and NIS
15
.
2
.
5Bi
o
l
og
i
ca
l
agents an
d
organic dusts 404
15.2.6 Occupational allergens
406
15.2.7 Hazards to reproductive

health
406
15.2.8 Occupational carcinogens
408
15.2.9 Psychological factors
409
15.2.10 New technologies
411
15.3 Public Health Impact of
Employment
412
15
.
3
.
1A
cc
id
enta
li
n
j
ur
i
es
412
15.3.2 Occupational diseases 412
15.3.3 Work and noncommuni-
cable disease
415

15.3.4 Work disability and mortal-
ity of working populations
416
15.4 Conclusions
416
References
419
16
.
1I
ntro
d
uct
i
on
424
16.2 Technological Accidents
with Environmental Effects
on Health
425
16.2.1 Chemical accidents
425
16.2.2 Radiation accidents
431
16.2.3 Accidents affecting food
and drinking-water
433
16
.
3A

cc
id
ents
Aff
ect
i
ng
Individuals
436
16.3.1 Traffic accidents
436
16.3.2 Accidental poisoning
439
16.4 Trends
441
16.5 Conclusions
441
References
442
17
.
1I
ntro
d
uct
i
on
444
17.1.1 Data limitations 444
17.2 State of the Environment

and Health
445
17.2.1 Air pollution
445
17.2.2 Water supply and quality
452
17
.
2
.
3S
o
lid
waste
459
17.2.4 Radiation 460
17.3 Discussion
462
17.4 Conclusions
462
References
463
Table of Contents 15
Part III
Analysis, Discussion, Conclusions and Recommendations
18 Estimated Health Effects of Environmental Exposure
and Role of Economic Sectors
19 Conclusions and Recommendations
18
.

1Eff
ects on
H
ea
l
t
h
o
f
Environmental Exposure 467
18.1.1 Situation in the European
Region
469
18.1.2 Global and transboundary
effects
490
18.1.3 Effects on health of non-
environmental factors
492
18.1.4 Discussion
493
18
.
1
.
5C
onc
l
us
i

ons
494
18.2 Role of Economic Sectors 496
18.2.1 Agriculture
497
18.2.2 Energy
500
18.2.3 Industry
504
18.2.4 Transport
508
18.2.5 Tourism
512
18.2.6 Conclusions
512
References
516
19
.
1I
ntro
d
uct
i
on
519
19.2 Economic Sectors 519
19.3 Environmental Health
Management
521

19.4 Economics, the Environ-
ment and Health
522
19.5 State of Human Health
522
19.6 The Database
522
19.7 Air Pollution
523
19.7.1 Ambient air
523
19.7.2 Indoor air
524
19.8 Water Supply and Quality
524
19.9 Wastewater and Surface
Water
525
19.10 Waste
526
19.11 Contamination of Food
and Drink
527
19.12 Exposure to Selected
Chemicals
528
19.13 Nonionizing Radiation
529
19
.

13
.
1Ul
trav
i
o
l
et ra
di
at
i
on
529
19.13.2 Electromagnetic fields 529
19.14 Ionizing Radiation
530
19.15 Residential Noise
530
19.16 Housing and the Indoor and
Urban Environments
531
19.17 Occupational Health
532
19.18 Accidents and Man-made
Disasters
534
19.19 Environmental Exposure in
some of the CCEE and NIS 535
19.19.1 The NIS
535

19.19.2 The CCEE
535
19.20 Global and Transboundary
Issues
536
19.21 Estimated Effects on
Health of Environmental
Exposure
536
19.22 Role of Economic Sectors
in Environmental Health
537
17
Acknowledgements
The European Centre for Environment and
Health of the WHO Regional Office for Eu-
rope prepared this volume through its divi-
sions in Bilthoven and Rome, together with
the coordination unit in Copenhagen. The
assessment of the situation in the fields of
health and the environment covering such a
vast area as the WHO European Region
would not have been possible without the ac-
tive support and collective efforts of a great
many contributing individuals and institu-
tions. The Regional Office is grateful to all
who participated in this effort, either as
authors, as reviewers or in any other capac-
ity. The extensive list of contributors is a
measure of the size and complexity of the

task.
The Organization is greatly indebted to all
ministries of health and of the environment
in the Region for their active support. The
network of national focal points for Concern
for Europe’s Tomorrow (CET), acting as
links between the national authorities and
the Regional Office, provided invaluable
help in data collection and evaluation. The
Regional Office is especially grateful to the
chairman and members of the Scientific Ad-
visory Board of the European Centre for En-
vironment and Health who, together with nu-
merous individual reviewers, carried out a
detailed scientific critique of the drafts and
provided sound advice on their improve-
ment. The close cooperation of other inter-
national bodies, especially the European En-
vironment Agency Task Force of the Euro-
pean Commission, is appreciated.
The Regional Office wishes to record its
special gratitude to Dr Barbara MacGibbon,
who undertook the very difficult task of
overall compilation and scientific editing of
the whole report. Without her invaluable
contribution, publication of this book would
not have been possible within the very lim-
ited time available.
National focal points for CET
Contributors

Q. Kodra (Albania)
A. Hrair (Armenia)
G. Liebel (Austria)
Galina Kurganskaya
(Belarus)
R. de Boeck (Belgium)
H. Mileva (Bulgaria)
M. Gunaric (Croatia)
K. Markvart (Czech
Republic)
H. Balling (Denmark)
R. Silla (Estonia)
A. Nevalainen (Finland)
Y. Coquin (France)
H. Lange-Asschenfeldt
(Germany)
G. Kamizoulis (Greece)
G. Dura (Hungary)
T. Ibsen (Iceland)
R. Ellard (Ireland)
R. Halperin (Israel)
G.A. Zapponi (Italy)
A. Zirnis (Latvia)
J. Ptashekas (Lithuania)
18 Acknowledgements
Other national contributors
J. Alexander (National Institute of Public
Health, Oslo, Norway)
T. Anavi (Tel Aviv University, Tel Aviv, Is-
rael)

E. Andronache (Institute of Hygiene and
Public Health, Bucharest, Romania)
S.L. Avaliani (Sisin Institute of Community
Hygiene, Moscow, Russian Federation)
A. Avni (Ministry of Health, Jerusalem, Is-
rael)
W. Babisch (Institute for Water, Soil and Air
Hygiene, Federal Health Office, Berlin,
Federal Republic of Germany)
B. Bayar (Ministry of Health, Ankara, Tur-
key)
R. Becher (National Institute of Public
Health, Oslo, Norway)
G. Bechu (Ministry of Health, France)
N.E. Billo (Federal Office of Public Health,
Bern, Switzerland)
K. Binysh (Department of Health, London,
United Kingdom)
G. Biro (National Institute of Food Hygiene
and Nutrition, Budapest, Hungary)
C E. Boström (National Environmental Pro-
tection Board, Stockholm, Sweden)
G. Brunborg (National Institute of Public
Health, Oslo, Norway)
J. Cachia (Department of Health, Valletta,
Malta)
R. Cachia Zammit (Department of Environ-
ment, Valletta, Malta)
J. Carmes (Ministry of Health, France)
P. Caruna (Public Health Laboratory, Vallet-

ta, Malta)
F. Cicogna (Ministry of Health, Rome, Italy)
M. Csanady (National Institute of Public
Health, Budapest, Hungary)
M. Dodic-Fikfak (University Institute for
Medicine and Social Welfare, Ljubljana,
Slovenia)
B. Drougge (National Environmental Protec-
tion Board, Stockholm, Sweden)
B. Duigu (Ministry of Reconstruction and
Settlement, Ankara, Turkey)
S. Dumitrache (Institute of Hygiene and
Public Health, Bucharest, Romania)
M. Eriksson (National Board of Health and
Welfare, Stockholm, Sweden)
N. Essiz (State Planning Organization, An-
kara, Turkey)
L. Ewetz (Institute of Environmental Medi-
cine, Stockholm, Sweden)
W. Fonahn (National Institute of Public
Health, Oslo, Norway)
E. Fröhlich (Federal Office of Public Health,
Bern, Switzerland)
M. Gauci (Industrial Hygiene Unit, Valletta,
Malta)
S. Gelberg (Ministry of Environmental
Quality, Jerusalem, Israel)
M. Gerber (Ministry of Environmental
Quality, Jerusalem, Israel)
Y. Gil (Ministry of Environmental Quality,

Jerusalem, Israel)
A. Goren (Tel Aviv University, Tel Aviv, Is-
rael)
F. Gösbebek (Turkish Atomic Energy Insti-
tute, Ankara, Turkey)
J. Gubernskiy (Sisin Institute of Community
Hygiene, Moscow, Russian Federation)
S. Güven (State Statistics Institute, Ankara,
Turkey)
P. Huberty-Krau (Luxem-
bourg)
A. Amato-Gauci (Malta)
R. Passeron (Monaco)
E. Lebret (Netherlands)
E. Dybing (Norway)
J.K. Ludwicki (Poland)
L. Delgado (Portugal)
M. Cucu (Romania)
N.F. Izmerov (Russian
Federation)
M. Synek (Slovakia)
M. Macarol-Hiti (Slovenia)
A. Fresno Ruiz (Spain)
K. Victorin (Sweden)
B. Marti (Switzerland)
S. Yüksel (Turkey)
A.M. Serdiuk (Ukraine)
E. Smales (United King-
dom)
Acknowledgements 19

J E. Haugen (National Institute of Public
Health, Oslo, Norway)
F. Hirka (National Institute of Public
Health, Budapest, Hungary)
A. de Hollander (RIVM, Bilthoven, Nether-
lands)
J. Hongslo (National Institute of Public
Health, Oslo, Norway)
A. Horvath (National Institute of Hygiene,
Budapest, Hungary)
M. Hristova (Institute of Radiobiology and
Radioprotection, Sofia, Bulgaria)
H. Huitfeldt (National Institute of Public
Health, Oslo, Norway)
J. Indulski (Institute of Occupational Medi-
cine, Lodz, Poland)
H. Isnard (Ministry of Health, France)
L. Ivanovska (Ministry of Health, Skopje,
The Former Yugoslav Republic of Mace-
donia)
M. Izrael (Institute of Radiobiology and
Radioprotection, Sofia, Bulgaria)
V. Kalivoda, Federal Environmental Agency,
Vienna, Austria)
K. Karlowski (National Institute of Hygiene,
Warsaw, Poland)
N. Kehlkovskiy-Sergeev (Institute of Indus-
trial Hygiene and Occupational Diseases,
Moscow, Russian Federation)
M. Kertész (National Institute of Hygiene,

Budapest, Hungary)
S. Khotimchenko (Institute of Nutrition
of the Russian Academy of Medical
Sciences, Moscow, Russian Federation)
B. Kihlström (National Institute of Public
Health, Oslo, Norway)
E. Kivisäkk (National Radiation Protection
Institute, Stockholm, Sweden)
V. Knizhnikov (Ministry of Health, Moscow,
Russian Federation)
M. Köhalmi (Ministry of Welfare, Budapest,
Hungary)
J. Korytkowsky (Ministry of Environmental
Protection, Warsaw, Poland)
Z. Koszarny (National Institute of Hygiene,
Warsaw, Poland)
D.I. Krammer, Federal Environmental Agen-
cy, Vienna, Austria)
N. Lazarus (Department of Health, London,
United Kingdom)
L. Licari, (Department of Health,Valletta,
Malta)
G. Lilleheil (National Institute of Public
Health, Oslo, Norway)
T. Lindner (Federal Ministry of Health,
Sport and Consumer Protection, Vienna,
Austria)
D. Lupulescu (Institute of Hygiene and Pub-
lic Health, Bucharest, Romania)
T. Majle (National Institute of Hygiene, War-

saw, Poland)
R. Maynard (Department of Health, Lon-
don, United Kingdom)
S. Maziarka (National Institute of Hygiene,
Warsaw, Poland)
T. Meredith (Department of Health, Lon-
don, United Kingdom)
V. Metodiev, National Centre of Hygiene
and Medical Ecology, Sofia, Bulgaria)
M. Micallef (Department of Health, Valletta,
Malta)
I. Miller (Institute of Hygiene and Epidemi-
ology, Prague, Czech Republic)
C. Milu (Institute of Hygiene and Public
Health, Bucharest, Romania)
B. Montaville (General Directorate for
Health, Paris, France)
C. Morawa (International Office of the Fed-
eral Environmental Agency, Berlin, Ger-
many)
H G. Mücke (Institute for Water, Soil and
Air Hygiene, Federal Health Office, Ber-
lin, Germany)
E. Ne’eman (Tel Aviv University, Tel Aviv, Is-
rael)
B. Nikiforov, National Centre for Hygiene
and Medical Ecology, Sofia, Bulgaria)
K. Ormerod (National Institute of Public
Health, Oslo, Norway)
O. Petursson, Office of Environmental Pro-

tection, Reykjavik, Iceland)
T. Popov (National Centre of Hygiene and
Medical Ecology, Sofia, Bulgaria)
V. Radmilovic (Federal Secretariat for La-
bour, Health, Veterans’ Affairs and Social
Policy, Belgrade, Federal Republic of Yu-
goslavia (Serbia and Montenegro))
T. Radunsky (Federal Environmental Agen-
cy, Vienna, Austria)
20 Acknowledgements
J. Rakhmanin (Sisin Institute of Community
Hygiene, Moscow, Russian Federation)
F. Ribarova (National Centre of Hygiene
and Medical Ecology, Sofia, Bulgaria)
D. Ricochon (Ministry of Health, France)
D. Riechman (Ministry of Health, Jerusa-
lem, Israel)
E. Rocco (Ministry of Health, Rome, Italy)
M. Rouge (Ministry of Health, France)
P. Rudnai (National Institute of Hygiene, Bu-
dapest, Hungary)
R. Skinner (Department of Health, London,
United Kingdom)
S. Slorach (National Food Administration,
Uppsala, Sweden)
T A. Stenström (National Bacteriological
Laboratory, Stockholm, Sweden)
J.R. Sveinsson (State Housing Board,
Reykjavik, Iceland)
N. Rusakov (Sisin Institute of Community

Hygiene, Moscow, Russian Federation)
E. Rydén (National Board of Housing, Build-
ing and Planning, Karlskrona, Sweden)
E. Sabir (Ministry of Labour and Social Se-
curity, Ankara, Turkey)
M. Sammut (University of Malta, G’Mangia,
Malta)
V. Scheftel (Ministry of Health, Jerusalem,
Israel)
R. Schembri (Public Health Laboratory, Val-
letta, Malta)
E. Schneider (Zentrales Arbeitsinspektorat,
Vienna, Austria)
T. Schossberger (Ministry of Health, Jerusa-
lem, Israel)
C. Serrano Carcia (Institute of Hygiene at
the Workplace, Madrid, Spain)
V. Shinev (Institute of Occupational Health,
Moscow, Russian Federation)
A. Spassov (National Centre of Hygiene and
Medical Ecology, Sofia, Bulgaria)
D.I. Stadler (Bundesministerium für Land-
und Forstwirtschaft, Vienna, Austria)
F. Störmer (National Institute of Public
Health, Oslo, Norway)
M. Sulcova (National Institute of Hygiene
and Epidemiology, Bratislava, Slovakia)
L.B. Sztanyik (National Institute of Radiobi-
ology and Radiohygiene, Budapest, Hun-
gary)

N. Tarkan (Middle East Technical Univer-
sity, Ankara, Turkey)
M. Tchutchkova (National Centre of Hygiene
and Medical Ecology, Sofia, Bulgaria)
S. Tekeli (Ministry of Trade and Industry,
Ankara, Turkey)
G. Tezcan (Ministry of Energy and Natural
Resources, Ankara, Turkey)
I. Thirouin (Ministry of Health, France)
S. Thorarinsson (Administration of Occupa-
tional Safety and Health, Reykjavik, Ice-
land)
I. Trettwer (Österreichisches Statistisches
Zentralamt, Vienna, Austria)
B. Tichacek (National Institute of Public
Health, Prague, Czech Republic)
E. Tacoronte (Ministry of Health and Con-
sumer Affairs, Madrid, Spain)
M. Tat (Institute of Hygiene and Public
Health, Bucharest, Romania)
H. Toksoy (Ministry of Agriculture and Vil-
lage Affairs, Ankara, Turkey)
U. Torsmark (National Environmental Pro-
tection Board, Solna, Sweden)
D. Tricard (Ministry of Health, France)
R. Tulbure (Institute of Hygiene and Public
Health, Bucharest, Romania)
G. Ungvary (National Institute of Occupa-
tional Heath, Budapest, Hungary)
L. Vella (Industrial Hygiene Unit, Valletta,

Malta)
T. Ulgen (Ministry of Health, Ankara, Tur-
key)
L. Ursu (Institute of Hygiene and Public
Health, Bucharest, Romania)
A. Vassallo (Department of Health, Valletta,
Malta)
A. Wadge (Department of Health, London,
United Kingdom)
K. Wahlberg (National Board of Occupa-
tional Safety and Health, Solna, Sweden)
H. Walker (Department of Health, London,
United Kingdom)
M. Waring (Department of Health, London,
United Kingdom)
S. Whitehead (Department of Health, Lon-
don, United Kingdom)
R. Zechner (Federal Ministry of Health,
Sport and Consumer Protection, Vienna,
Austria).
Acknowledgements 21
Thematic contributors
U. Ackerman-Liebrich (University of Basle,
Switzerland)
G. Andreottola (Istituto per l’Ambiente,
Milan, Italy)
M.E. Apeldoorn (RIVM, Bilthoven, Nether-
lands)
J.H. Bernhardt (Institute of Radiation Hy-
giene, Neuherberg, Germany)

C. Corchia (University of Sassari, Italy)
R.B. Cundall (Medical Research Council,
Chilton, United Kingdom)
H. Dovland (Institute for Air Research, Lil-
leström, Sweden)
K. Gerigk (Robert von Ostertag Institute,
Berlin, Germany)
R.J. Gilbert (Central Public Health Labora-
tory, London, United Kingdom)
A. Henne (Medizinisches Institut für Um-
welthygiene, Düsseldorf, Germany)
D. Hill (Environmental Resources Limited,
London, United Kingdom)
G. Jukes (Institution of Environmental
Health Officers, London, United King-
dom)
E.D. Kroese (RIVM, Bilthoven, Nether-
lands)
S. Lagorio (Istituto Superiore di Sanità,
Rome, Italy)
F. Langeweg (RIVM, Bilthoven, Nether-
lands)
I. MacArthur (Institution of Environmental
Health Officers, London, United King-
dom)
K. Martignoni (Institute of Radiation Hy-
giene, Neuherberg, Germany)
R. Mnatsakanian (Moscow, Russian Feder-
ation)
Eva Nielsen (National Food Agency, Sø-

borg, Denmark)
R. Novick (Potomac, USA)
O. Juhl Pedersen (Technical University, Co-
penhagen, Denmark)
P. Peterson (MARC, London, United King-
dom)
J. Rantanen (Finnish Institute of Occupa-
tional Health, Helsinki, Finland)
J. Roberts (Adhealth Ltd, United Kingdom)
F. Sella (Apples, Switzerland)
R.M.C. Theelen (RIVM, Bilthoven, Nether-
lands)
P. Teufel (Robert von Ostertag Institute, Ber-
lin, Germany)
B.T. Williams (University of Sheffield,
United Kingdom)
E. Wirth (Institute of Radiation Hygiene,
Neuherberg, Germany)
M. Wohlen (Gothenburg, Sweden).
Scientific reviewers
Scientific Advisory Board
Sir Donald Acheson (Chairman, London
School of Hygiene, United Kingdom)
A.M. Kellerer (Institut für Strahlenbiologie,
Germany)
M. Maroni (International Centre for Pesti-
cide Safety, Italy)
G. Pershagen (National Institute of Environ-
mental Medicine, Sweden)
J.K. Piotrowski (Institute of Environmental

Research, Poland)
J. Rantanen (Institute of Occupational
Health, Finland)
U. Schlottmann (Federal Ministry for the
Environment, Nature Conservation and
Nuclear Safety, Germany)
V. Silano (Ministry of Health, Italy)
J. Weicherding (General Directorate of
Health, France)
T.B. Zeltner (Federal Office of Public
Health, Switzerland)
B.C.J. Zoeteman (Ministry of Housing,
Physical Planning and Environment, Ne-
therlands).
22 Acknowledgements
Individual scientific reviewers
T. Hancock (Public Health Consultant,
Kleinburg, Ontario, Canada)
P. Kulling (National Poison Information
Centre, Stockholm, Sweden)
M.D. Lebowitz (University of Arizona, Tuc-
son, USA)
D. Larré (Director, Industry and Environ-
ment Office, UNEP, Paris, France)
J.L. Larsen (National Food Agency, Søborg,
Denmark)
C.J. Macfarlane (Ontario International Cor-
poration, Government of Ontario, Cana-
da)
E. Morava (National Public Health and

Medical Officer Service, Pécs, Hungary)
G. Salomon (Gentofte Hospital, University
of Copenhagen, Denmark)
A. Parving (Department of Audiology, Bis-
pebjerg Hospital, Denmark)
A. Pintér (National Institute of Hygiene, Bu-
dapest, Hungary)
R. Visser (OECD, Paris, France)
G. Winneke (Medizinisches Institut für Um-
welthygiene, Düsseldorf, Germany).
Project Group of the Europe’s environment
report
J P. Ribaut (Council of Europe)
J. Benes, Jaroslav Mejzr (ex-Czechoslovakia)
T. Moth Iversen (Denmark)
G. Hilf (Eurostat)
L. Hopkins, Z. Karpowicz, T. Rajamets
(IUCN)
K. van Egmond, R.M. van Aalst, Ad Minder-
houd (Netherlands)
C. Avérous, C. Chung, P. Schreyer (OECD)
M. Leonor Gomes (Portugal)
A.M. Goudyma, D. Kolganov (Russian Fed-
eration)
T. Litscher (Switzerland)
J. Martin (United Kingdom)
A. Kahnert (UNECE)
A. Diamantidis, B. Ivanov, S. Jaakola
(UNEP)
I. Waddington, J. Zakonyi, M. Krzyzanow-

ski, B. Lübkert-Alcamo (WHO)
P. Bourdeau (Head of DG XI, EEA-Task
Force)
D. Stanners (DG XI, EEA-Task Force, Pro-
ject Manager of the Europe’s environment
report).
WHO Regional Office for Europe
(a) European Centre for Environment and
Health
B. MacGibbon (Scientific Editor)
K. Baverstock, R. Bertollini, B. Fenger,
K. van der Heijden, R. Kersauze, M. Krzyza-
nowski, B. Lübkert-Alcamo, P. Marchandise,
R. Merineau, P. Rushbrook, R. Stern,
S. Tarkowski, I. Vlachonikolis, I. Wadding-
ton, P. Weigert, M. Younes, J. Zakonyi (Pro-
ject Officer for the CET report).
(b) X. Bonnefoy, M.S. Burgher, P. Charlton,
O. Espinoza, E. Grandjean, D. Kello, F. La
Ferla, A. Nanda, A. Nossikov, R. Prokhors-
kas, K. Runeberg, L. Saliba, M. Shabanah,
M.J. Suess, F. Theakston.
WHO Headquarters
E. Giroult, T. Kjellström.
23
Introduction
Many of the great advances in public health
during the nineteenth and twentieth cen-
turies resulted from the realization that un-
satisfactory water supplies, sanitation, work-

ing conditions, housing, food and air quality
were major contributors to disease and short
lifespans. More recently, protection of the
environment for its own sake and the main-
tenance of biodiversity for future generations
have become important political issues
throughout the world. The relationship of
human health and wellbeing to environ-
mental influences is an important dimension
of these issues.
The relationship between environmental
factors and health is complex. Many diseases
have multifactorial causes and the influence
of lifestyles and social and economic factors
may be difficult to separate from environ-
mental exposures.
Over recent decades, much of the WHO
European Region has experienced rapid
economic growth, but the benefits of in-
creased overall prosperity have not always
been accompanied by adequate measures to
The Setting
safeguard the quality of the environment.
This has resulted in a wide range of direct
threats to human health as well as potential
indirect effects, including some that may
occur in the future as a result of the unsus-
tainable nature of much economic develop-
ment.
The situation is far from uniform. Basic

health statistics
a
show a general improve-
ment in levels of health within the European
member countries of the Organisation for
Economic Co-operation and Development
(OECD) as assessed by infant and total mor-
tality rates, life expectancy and the incidence
of certain diseases. By contrast, no improve-
ment and in some aspects a deterioration in
health status has occurred in the countries
of central and eastern Europe (CCEE)
b
and
the newly independent states (NIS) of the
former USSR over the last two decades. In
addition, considerable variations occur
a
Health for all database of the WHO Regional
Office for Europe.
b
The CCEE comprise Albania, Bulgaria, the Czech
Republic, Estonia, Hungary, Latvia, Lithuania,
Poland, Romania, Slovakia and the countries
emerging from the former Yugoslavia.
The Setting 23
The Genesis of Concern for
Europe’s Tomorrow
24
The Development of Concern for

Europe’s Tomorrow
26
The Scope and Purpose of Concern
for Europe’s Tomorrow
27
Limitations and Constraints 28
Beyond Concern for Europe’s
Tomorrow
28
References
29
24 Introduction
among different social groups within individ-
ual countries of the Region, the poor every-
where suffering more ill-health than the
better off. If appropriate and cost-effective
action is to be taken to create a greater de-
gree of equity in health throughout the Re-
gion, a better understanding must be reached
of the role of the environment in influencing
health, compared with social and economic
inequalities, lifestyles and the quality of
health care systems.
The definition of environmental health
given in the European Charter on Environ-
ment and Health [1] should be borne in
mind:
Environmental health includes both the direct
pathological effects of chemicals, radiation and some
biological agents, and the effects (often indirect) on

health and wellbeing of the broad physical, psycho-
logical, social and aesthetic environment, which in-
cludes housing, urban development, land use and
transport.
While public health policies are understand-
ably mainly directed towards relieving so-
ciety of disease and premature death, the en-
vironment should also be considered as a re-
source for enhancing health and wellbeing.
People aspire to live in communities free of
environmental hazards, with decent homes
in which to raise their families, with oppor-
tunities for employment, education and cul-
ture, and with pleasant and harmonious sur-
roundings that facilitate recreation and so-
cial contact and maintain a healthy and di-
verse ecosystem. Effective environmental
protection, in its widest sense, provides a
framework for many of these aspirations, as
part of enlightened and sustainable socioeco-
nomic development.
While these are desirable aims, already
within the reach of many people in the Re-
gion, the far more basic needs of many
others must also be recognized and dealt
with as a matter of high priority. Many mil-
lions of people in the Region still lack at
least one of the essential prerequisites of en-
vironmental health: safe water, clean air,
sanitation and shelter. A substantial number

are without the first and most fundamental
prerequisite for health, namely peace. Reha-
bilitation of public services essential for envi-
ronmental health and resettlement of large
numbers of refugees will be major inter-
national tasks when hostilities have ceased.
If countries are to improve the health of their
people, they must know what environmental
conditions prevail. Concern for Europe’s To-
morrow was launched to assess the state of
environmental health in the Region. To ex-
plain fully how this project came about, we
must go back a little in time.
In 1980, the Member States of the WHO
European Region adopted a common Euro-
pean strategy for attaining health for all [2].
This called for fundamental changes in ap-
proaches to health development. It focused
on four areas of concern: lifestyles and
health, the risk factors affecting health and
the environment, the reorientation of the
health care system, and the mobilization of
political, managerial and technological sup-
port to bring about these changes. In 1984,
the Member States of the Region approved
38 regional targets encompassing these
areas. Their adoption proved to be a decisive
event that gave a strong impetus to the wide
political acceptance and implementation of
the European health for all strategy. In many

countries, the concepts, principles and strat-
egies have already become reflected in
national, regional and local policies. They
have also provided a solid basis for health de-
velopment in the CCEE and NIS, which has
been greatly affected by political change in
the last five years. While retaining their basic
structure, the original targets were updated
in 1991 [3]. As in 1984, nine targets are di-
rectly concerned with aspects of environ-
mental health.
Target 11 – Accidents
By the year 2000, injury, disability and death
The Genesis of Concern for
Europe’s Tomorrow
Introduction 25
arising from accidents should be reduced by
at least 25%.
Target 18 – Policy on environment and health
By the year 2000, all Member States should
have developed, and be implementing, pol-
icies on the environment and health that en-
sure ecologically sustainable development,
effective prevention and control of environ-
mental health risks and equitable access to
healthy environments.
Target 19 – Environmental health manage-
ment
By the year 2000, there should be effective
management systems and resources in all

Member States for putting policies on en-
vironment and health into practice.
Target 20 – Water quality
By the year 2000, all people should have ac-
cess to adequate supplies of safe drinking-
water and the pollution of groundwater
sources, rivers, lakes and seas should no
longer pose a threat to health.
Target 21 – Air quality
By the year 2000, air quality in all countries
should be improved to a point at which rec-
ognized air pollutants do not pose a threat to
public health.
Target 22 – Food quality and safety
By the year 2000, health risks due to micro-
organisms or their toxins, to chemicals and
to radioactivity in food should have been sig-
nificantly reduced in all Member States.
Target 23 – Waste management and soil pol-
lution
By the year 2000, public health risks caused
by solid and hazardous wastes and soil pollu-
tion should be effectively controlled in all
Member States.
Target 24 – Human ecology and settlements
By the year 2000, cities, towns and rural
communities throughout the Region should
offer physical and social environments sup-
portive to the health of their inhabitants.
Target 25 – Health of people at work

By the year 2000, the health of workers in all
Member States should be improved by mak-
ing work environments more healthy, reduc-
ing work-related disease and injury, and pro-
moting the wellbeing of people at work.
The need to achieve a better understanding
of the relationship between environmental
factors and the health of individuals and
communities, together with the clear need
for the environment and health sectors at all
levels of government to work closely to-
gether, was recognized by the first European
Conference on Environment and Health,
held in Frankfurt-am-Main, Federal Republic
of Germany, in December 1989.
The Conference culminated in the adop-
tion, by ministers of health and of the en-
vironment and other senior representatives
from 29 European countries and by the
Commission of the European Communities,
of the European Charter on Environment
and Health [1]. The Charter sets out a broad
framework for action by all levels of govern-
ment, by all sectors of society and at the in-
ternational level.
Subsequently, the WHO Commission on
Health and Environment was established
and produced a report entitled Our planet,
our health [4] in preparation for the United
Nations Conference on Environment and

Development in Rio de Janeiro in 1992. This
report analysed, within the global perspec-
tive, the various ways in which the environ-
ment interacts with health in the context of
socioeconomic development, and provided a
series of broad recommendations for action
at international, national and local levels.
The Rio Conference endorsed the so-called
Agenda 21 [5], an action plan for the twenty-
first century that sets a far-seeing course to-
wards sustainable development. Its health
component largely reflects the findings of
the WHO Commission and acknowledges
that, within the overall principle of sustain-
ability, major changes in approach are
required if health impairment due to environ-
mental degradation is to be arrested and fu-
ture adverse environmental impacts on
health prevented.
In response to Agenda 21, a global strat-
egy for health and the environment was en-