”Environment & Health Indicators” Options for actions and recommendations

under the framework of the European Environment and

Health Strategy (COM 2003)338 final)

Produced by the Technical Working Group on Indicators & Priority diseases

subgroup Environment & Health Indicators

23 February 2004

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This report reflects the opinions of the members of the Working Group and it highlights the

different opinions contained within the group where appropriate. It should not be considered as an official statement of the position of the European Commission.

Further information relating to this work is available on the project website: www.brussels-conference.org or from the Technical Secretariat: Dr. Anke Joas BiPRO GmbH Grauertstr. 12 81545 Munich Germany Telephone +49 89 18979050 Facsimile +49 89 18979052 Email: anke.joas@bipro.de

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List of members TWG Dafina Dalbokova* WHO European Centre for Environment and Health, Bonn Office

Marie-Christine De Wolf* EPHA, Environmental Network, Belgium

Antonio Doronzo DG Sanco

Ingeborg Fiala Ministry of the Agriculture, Forestry, Environment and Water Management, Austria

Michael Hübel DG Sanco

Patricia Koundakjian EUROFER, Belgium

Michal Krzyzanowski WHO, Regional Office for Europe

Paloma Martin ENSP European Network for smoking Prevention

Mark McCarthy* European Public Health Association, University College London,UK

Antoni Montserrat DG Sanco

Monica Nordberg* Institute Environmental Medicine, Karolinska Institutet, Sweden

Anna Páldy National Centre for Public Health, Hungary

Dirk Pallapies* BASF AG

Philippe Pirard* INVS, National Institute of Public Health Surveillance, France

Sylvia Medina* Institut de Veille Sanitaire, France

Cesaltina Ramos Portugal

D. Benjamin Sanchez Fernandez-Murias

Instituto de Salud Carlos III/ Escuela Nacional de sanidad

Ulrike Ravens-Sieberer Robert Koch Institut, Germany

Luciana Sinisi* APAT, National Environment Agency, Italy

Vesna Smaka Kincl* Municipality of Maribor - Environmental Protection Agency, Slovenia

Brigit Staatsen* RIVM, National Institute of Public Health and Environment, The Netherlands

David Stanners* EEA

Jürgen Thelen* Federal Environmental Agency, Germany

Ronan Uhel EEA

Friedrich Wiebel ENSP European Network for Smoking Prevention

Chair: Brigit A.M. Staatsen Co-chair: Vesna Smaka Kincl The subgroup is assisted by Anke Joas from BIPRO as a technical consultant and by Michael Hübel from the European Commission, DG Sanco * contributors to the report

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Table of Contents Executive summary.................................................................................................................... 5

1 Background and aims ...................................................................................................... 10

1.1 Framework for Environment and Health Information exchange and impact assessment ............................................................................................. 11

1.2 Use and limitations of indicators....................................................................... 12

2 Proposals for an improved information exchange and assessment process to support E&H decision making ........................................................................................ 15

2.1 Options related to the organisational framework for indicator development, management and use in the European Region............................ 15

2.2 Options for action on methodology................................................................... 21

3 Proposals for actions in SCALE with regard to data gaps .............................................. 24

3.1 Introduction....................................................................................................... 24

3.2 Proxy indicators for exposure like distance of dwellings to roads, power lines, industry.................................................................................................... 24

3.3 Bio- indicators for emerging threats................................................................... 25

3.4 (Proxy)Indicators for health impacts and well being ........................................ 25

3.5 Develop indicators for vulnerable groups and vulnerable periods in life ......... 25

3.6 Develop methods to monitor and evaluate effect of combined exposures (e.g. integrating indicators) ............................................................................... 26

3.7 Further develop the use of aggregated indicators.............................................. 26

3.8 Harmonisation of existing information and indicators...................................... 27

3.9 Improve data –collection and data- linkage methods ......................................... 28

4 Proposals for improved monitoring and health impact assessments............................... 29

4.1 Develop mechanisms for sharing experiences and improving integrated assessments........................................................................................................ 29

4.2 Develop tools for improved linkage of EH data with geographical information........................................................................................................ 30

4.3 Biobanks for assessment of long-term effects and multicausality................... 30

4.4 Proposal to improve current monitoring systems.............................................. 30

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4.5 Evaluate present scientific information and literature for new E&H indicators. .......................................................................................................... 31

5 Proposals to support and facilitate decision-making and track effects of preventive actions .............................................................................................................................. 32

5.1 Indicators for policy performance..................................................................... 32

5.2 Develop tools to enhance informed decision-making ....................................... 32

6 Proposals for improved communication and education .................................................. 34

6.1 Develop tools for awareness raising and improved communication to the different target communication audiences ........................................................ 34

6.2 Promotion of environmental health/environmental medicine ........................... 36

7 Annex: Reporting formats ............................................................................................... 37

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Executive summary

To support the further development of a European Community Environment and Health Action Programme reliable information is essential to set priorities for action, track the progress and evaluate the effectiveness of the actions that will be carried out. The problem is that current monitoring programmes and related information systems are typically driven from the environmental or health perspective and not integrated. Thus, it is difficult to provide environment and health (E&H) relevant data to enable policy-tracking and international comparisons.

Thus, to enhance the process towards informed priority setting, developing and tracking of actions and communication for SCALE, the Action Programme 2004-2010 should:

1. Endorse well-coordinated activities to establish and implement environment and health indicator reporting and assessment serving the SCALE needs and applying standardised methodological guidelines.

2. Set up a European and national decision-making process on the progressive development and implementation of the information system together with a timeframe and milestones to make it accountable.

3. Set up an organisational framework (including mandate and responsibilities) to establish, co-ordinate and manage indicator development and data collection, assessment and reporting in the European Region, ensuring continuity and further development of existing mechanisms for regular reporting following common methods.

The framework should integrate the following components:

• A set of environmental health indicators linked to assessment and reporting mechanisms, consisting of: – a core set of ind icators covering critical points in the causal chain for priority topics

(readily available and highly standardized); – an extended set of indicators not yet available or standardized enough; – Indicators recommended for development.

• Methodology for effective analysis, assessment and reporting: Guidelines for health impact assessments (HIA) or comparative risk assessment (CRA) and cost-benefit analyses need to be made available. These guidelines should include the latest state of the art on methodology.

• Evidence review: The information on health impacts and effectiveness of policy measures should be regularly adjusted according to the latest results from ongoing scientific reviews and projects. This may lead to adjustments of indicators and fact-sheets on the state of the art.

• Access to the information and communication about the results: Different instruments should be designed to inform the public and all responsible for policy-making, tracking and evaluation. A combination of a website, newsletters, fact-sheets and periodic indicator-based reports can be thought of. Electronic information systems should be set up to (a) give periodic feedback and update mechanism among Member States and (b) to raise awareness among eg health professionals.

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The major recommendations are related to the elements of this framework:

1. Establish an organisational framework for indicator development, management and use in the European Union by means of one of the following alternatives:

• A European Steering Body: representatives of the European Commission (DG Env, DG SANCO, EUROSTAT), EEA, international organisations (WHO, UNECE, ...), MS and civil society ,and working group of national & international representatives

• a "central" institution/body/agency

o new environment &health agency

o "virtual agency"

o expansion of the mandate of an existing agency in the field

• a network of environment and health information with national focal points, focal points at DG Sanco, DG Environment, EUROSTAT, EEA and collaborating centres of excellence

• a shared information infrastructure

• links to academic and policy communities to support systematic review of evidence

• national networks

Or by a combination of the above alternatives

The tasks of a steering body or central E&H institution would be (a) To develop a stepwise process of approval and selection of system elements (b) To oversee the future development of the information base & to advise on current policy issues (c) To plan the work on the various system elements, coordinate relevant inputs of the partners, in particular of international bodies such as WHO already involved in the Environment and Health Information System process.

A new Agency i.e. Environment and Health Agency (EHA) could easily be set up and extended to work in full condition within a short time.. A collaborative arrangement between existing bodies, with a separately defined virtual or real entity/ies (eg steering committee and working group) may be more realistic, and cheaper and efficient to run in the short to medium term.

Economies of scale and the basic arguments behind a new E&H information system encouraging sharing information, integration of environment and health and between sectors and themes, providing common access to data and possibilities to link and inter-relate diverse data sets, all argue for the new system to be built on the existing EEA and WHO building blocks. Separate systems have the danger of leading to duplication and increased burdens for the countries with attendant higher costs and the possibility to lead to isolation and fossilisation. Building on existing systems and combining forces with existing experiences at international and national/regional levels will lead to a more dynamic overall process which can gain from the sharing of experiences.

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2. Develop harmonised methodologies for indicator development, data collection, analysis and reporting

by means of:

• A harmonisation of existing indicator sets

A flexible approach towards implementation of EH indicators is proposed to enable the use of existing indicator sets, databases and current methodologies, while building towards the goal of a core set of harmonized indicators for the EU-region. While the strategy aims for continuous improvement and comparability among the indicators for the different member states, the approach in the first cycle however does not insist primarily upon a common set of indicators and collection methods. Countries should not wait for an internationally harmonised set.

A better, more comprehensive indicator system with regard to SCALE would help to identify the health endpoints of key concern as well as possible trends in their incidence/prevalence. The same would be the case with regard to the environmental factors. Prioritisation would be facilitated; even early warning signs with regard to specific environmental burdens could be detected. This would help both the allocation of financial and personal resources as well as the prioritisation of public health actions. Geographical differences, partly probably related to social differences, could be detected and, thus, appropriately addressed.

Some other pros are related to the harmonisation of the process such as comparability between various regions, facilitation of data transmission, storage and exchange as well as exchange of human resources and financial savings due to standardisation.

The only real disadvantages related to actions in this field seem to be the costs of data collection and storage. In addition, it might be difficult to persuade all involved stakeholders as well as the public that the information to be obtained is treated with confidentiality and not under danger of being misused.

Another difficulty might be the necessary standardisation of the data to be collected from the different Members States. It might be difficult to persuade the different stakeholders to provide the date in an ‘imposed’ way. Attention should be payed to associate all stakeholders to the building of the Environment and Health Information System since the very beginning.

• Guidelines and instruments for harmonised data collection and reporting:

The proposed indicators will initially be based on the existing data reporting systems and harmonised with the existing practices of information reporting. The E&H policy needs and the EU EH AP (SCALE) must be considered. Methods for analysis, reporting and dissemination of the information need to be developed further, using the experience of WHO and EEA, and should be harmonised with the national reporting practices and obligations. The information will be updated and the methodological guidelines adjusted on the basis of systematic reviews of the scientific evidence and policy, as well as from lessons learnt about the feasibility and relevance of the system. The guidelines should identify possible improvements and standardisation of the information most relevant for EH assessment. They will include recommendations for collection of new information and further development of harmonised instruments e.g. adjustment of HIS/HES surveys (Eurostat).

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3. Actions for SCALE with respect to knowledge gaps (research needs)

These are preliminary suggestions which need further discussion within the framework as described above:

• Develop and test the applicability and use of new indicators in the E&H area, such as proxy indicators for exposure (e.g. distance of sources to dwellings) and effects (e.g. medication use, school absenteeism), bio-indicators, indicators for vulnerable periods (eg indicators for pre-, peri- and postnatal exposure) and vulnerable groups, aggregated indicators (eg DALYS, COI).

• Develop methods to monitor and evaluate effect of combined exposures (e.g. integrating indicators)

• Harmonisation of existing indicators in the field of respiratory diseases, neurodevelopmental disorders/cognition

4. Proposals for improved analysis, assessment and reporting

by means of: • Developing mechanisms for sharing experiences and improving integrated

assessments and cost-benefit analyses, esp on a local level:

• Develop tools for improved linkage of EH data with geographical information Enhance possibilities for linkages of spatial data (eg from INSPIRE) with health and lifestyle data

• Methodologies for assessment of externalities of health (methodology is lacking for children

• Review use of existing biobanks as tools for studying long-term and combined effects

• Pilot tools to support informed decision-making/stakeholder discussions

• Develop policy performance indicators (e.g. distance-to-target) indicators . To assess the effectiveness of a new environment and health policy step by step tracking of the process is needed. Indicators to track and evaluate policy performance need to be developed already at the stage of policy development.

5. Proposals for improved communication and education

by means of: • Tools for awareness raising and improved communication to the public: Improve

communication with stakeholders at international level by developing a combination of electronic information systems , website, fact-sheets and periodic newsletters and indicator-based reports. Electronic information systems could be set up to (a) give periodic feedback and update mechanism among Member States and (b) to raise awareness among eg health professionals.

o Improve use of international (Eurobarometer) and national population surveys to get information on risk perception /concern population

o Promotion of environmental health/Environmental medicine training & raise awareness for quality requirements at involved parties/professionals

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o strengthen environmental health/medicine in the medical curricula (university, other health professions)

o strengthen interdisciplinary training programmes

o develop training programmes for teachers in day care centres and schools

• Promote harmonisation of environmental health/medicine and its organisation and

structure throughout Europe

o harmonised definition of Environmental Medicine throughout Europe

o develop harmonised degrees in Environmental Medicine

o harmonised organisation and structure on governmental and regional level, e.g. one ministry taking the key responsibility for environmental health/medicine issues

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1 Background and aims

Background

The SCALE-(Science- Children-Awareness Legal instruments-Evaluation)- initiative aims at providing information for a Community Environment and Health Action Programme. To support this process reliable information is essential in order to set priorities for action, track the progress and evaluate the effectiveness of the actions that will be carried out. Indicators can play a role in turning complex data from surveillance and monitoring programmes into relevant information and thus supports decision-making. The problem is that currently information available from monitoring programmes is of varying quality, not always comparable, not complete and not necessarily available. Many different data holders are involved. Current monitoring programmes and related information systems are typically driven from the environmental or health perspective and not integrated. Thus, it is difficult to provide environment and health (E&H) relevant data to enable policy-tracking and international comparisons. One exception is the Environment and Health Information System initiative of WHO-Europe (WHO-EHIS). The current system of the WHO needs further development though in order to provide comparable information. In addition, it will need some adjustments to make it better fit the needs of the SCALE-strategy. Mechanisms for interagency cooperation and a shared information infrastructure are urgently needed. It is vital that the existing international agencies developing environment and health indicators and assessment procedures (WHO, EEA, EUROSTAT) should reinforce their cooperation to ensure the development of a harmonised set and information system that can serve the different purposes of the organizations and countries. These are the conclusions of a recent inventory of (inter)national projects and existing Environment and Health indicator sets and information systems (see Baseline-report, January 2004).

Objective: Shared and improved E&H information and assessment

In this report the actions and steps needed towards shared and improved E&H information and assessment at a European level are described. The main action urgently needed is the development of an organisational framework for indicator development and the management of data collection, assessment and reporting in the European Region. The main prerequisite is to make better use of what is already there, but maybe not easily available or comparable. Secondly, the system to be implemented should be flexible, allowing for differences in user needs at a regional, national or international level. Thirdly, duplication of work and unnecessary reporting burdens should be avoided. Finally, the system to be developed needs to fit with the information needs of the SCALE-initiative and the Action Programme.

Benefits and disadvantages related to actions for improved E&H Information

A better, more comprehensive indicator system with regard to SCALE would help to identify the health endpoints of key concern as well as possible trends in their incidence/prevalence. The same would be the case with regard to the environmental factors. Prioritisation would be facilitated; even early warning signs with regard to specific environmental burdens could be detected. This would help both the allocation of financial and personal resources as well as the prioritisation of public health actions. Geographical differences, partly probably related to social differences, could be detected and, thus, appropriately addressed.

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Some other pros are related to the harmonisation of the process such as comparability between various regions, facilitation of data transmission, storage and exchange as well as exchange of human resources and financial savings due to standardisation.

The only real disadvantages related to actions in this field seem to be the costs of data collection and storage. In addition, it might be difficult to persuade all involved stakeholders as well as the public that the information to be obtained is treated with confidentiality and not under danger of being misused.

This report starts with the options for the organisational framework (chapter 2), followed by recommendations to adjust current indicator sets and databases to better fit the information needs of SCALE (chapter 3). The report ends with actions in the field of assessment (chapter 4), communication (chapter 5) and policy review and planning (chapter 6). In the annex the recommended actions are described in more detail. Below, the framework needed to integrate indicator development and the management of data collection, assessment and reporting is summarised (1.2). This chapter concludes with a summary of the use and limitations of indicators, which should be kept in mind while further developing and using indicators (1.3).

1.1 Framework for Environment and Health Information exchange and impact assessment

To enhance the process of informed EH decision-making, development and evaluation of actions and communication in the EU, a framework is needed which integrates the following components (figure 1.1):

• A set of environmental health indicators linked to assessment and reporting mechanisms, consisting of:

– a core set of indicators covering critical points in the causal chain for priority topics (readily available and highly standardized);

– an extended set of indicators not yet available or standardized enough;

– Indicators recommended for development.

• Assessment: Guidelines for health impact assessments (HIA) or comparative risk assessment (CRA) and cost-benefit analyses need to be made available. These guidelines should include the latest state of the art on methodology and values which can be used for the calculations. Methodology for effectively analysing (at regional, national and international level) and reporting the results is another element.

• Evidence review: The information on health impacts and effectiveness of policy measures should be regularly adjusted according to the latest results from ongoing scientific reviews and projects. This may lead to adjustments of indicators and fact-sheets on the state of the art.

• Access to the information and communication about the results:

• Different instruments should be designed to inform the public and all responsible for policy-making, tracking and evaluation. A combination of a website, newsletters, fact-sheets and periodic indicator-based reports can be thought of. Electronic information systems should be set up to (a) provide give periodic feedback and update mechanism among Member States and (b) to raise awareness among e.g. health professionals.

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WHO European Centre for Environment and HealthWHO European Centre for Environment and Health

Environment and Health Information System –main system elements

Indicators Assessment& reporting

Adjusting & UpdatingPolicy review

HIA / SIA

Evidence review

Data ge

neratio

n Access & Communication

Figure 1-1: Environment and Health Information system: the main elements. Source: WHO, 2004

1.2 Use and limitations of indicators

Indicators are used to provide a picture of a complex system that cannot be easily or totally described. We require some form of measure or simplifications of reality to assess status, track changes, set goals and protect and improve human health and the environments upon which we rely. Examples of E&H indicators, which have been successfully used to highlight problems and to track progress are eg the levels of dioxins and PCBs in breast-milk and lead-blood levels in children in combination with indicators on trends in emissions (see also box 2).

Most indicators are built on multiple datasets in time and space which are combined by a certain methodology to construct the indicator.

BOX 1:

Environment and health (E&H) indicators can be defined as indicators, which give an expression of the link between environment and health, are targeted at an issue of specific policy or management concern and presented in a form, which facilitates interpretation for effective decision-making and communication with the public. We can distinguish descriptive indicators (providing baseline information on spatial and temporal trends in environment or human health, performance indicators (linked to a reference value or policy target) and efficiency indicators (showing efficiency of political measures).

Since indicators are simplifications, care must be taken with their interpretation. It should not be forgotten that indicators only have a sentinel function. The relationship between environment and (children’s) health is complex and not always evident, due to the fact that most diseases are the result of a combination of endogenous and exogenous risk factors.

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BOX 2 Health benefits of a ban on coal sales in Dublin

In 1990, the Irish government introduced a ban on the marketing, sale, and distribution of bituminous coal within the city of Dublin. Concentrations of air pollutants and death rates for 72 months before and after the ban, adjusting for weather, season and changes in population structure, was studied. Black smoke concentrations were reduced by two-thirds and sulphur dioxide by a third. Death rates were reduced by 287 deaths per year: total non-trauma were reduced by 5.7%, cardiovascular by 10.3%, respiratory by 15.5%, other deaths by 1.7%. The authors of the study concluded: “the ban on coal sales within Dublin County Borough led to a substantial decrease in concentration of black smoke particulate air pollution, a reduction of 243 cardiovascular deaths and 116 fewer respiratory deaths per year” (source1).

Different information needs: develop flexible indicator sets

The main purposes of indicators are to:

• describe trends in time and space

• track effect, progress and efficiency of actions

• provide a warning (eg an increase in exposure levels/emissions of (uncertain/suspected) high-risk chemicals)

Three main user groups can be distinguished with different, but also overlapping information needs:

• Professionals involved in the process of policy development, tracking (monitoring) and evaluation need to know: (1) the actual environment and health situation in their country to set priorities (information on health impacts and risk groups, economic and social impact), (2) about trends in emissions and exposures to track progress/ effect of

1 Clancy L, Goodman P, Sinclair H, Dockery D. Effect of air-pollution control on death

rates in Dublin, Ireland: an intervention study. Lancet 2002;360:1210-14.

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(preventive) policies, (3) in time about emerging is sues they may have to act on (including planning, research)

• The public has the right to know about the actual E&H situation in their surroundings and whether actions have been undertaken. They want to have understandable information about actual and perceived health risks. The Aarhus convention and some EU-guidelines prescribe free access to environmental information and the publication of e.g. air pollution and noise-maps.

• Professionals involved in the process of E&H training want to know about the evidence base for environment and health risks and (trends in) the environment and health situations in their country. Researchers can use information about temporal and spatial trends for identification and prioritisation of research areas.

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2 Proposals for an improved information exchange and assessment process to support E&H decision making

2.1 Options related to the organisational framework for indicator development, management and use in the European Region

The Action Programme 2004-2010 should:

• Endorse well-coordinated activities to establish and implement environment and health indicator reporting and assessment serving the SCALE needs and applying standardised methodological guidelines

• Set up [European and national] decision-making process on the progressive development and implementation of the information system together with a timeframe and milestones to make it accountable

• Endorse a framework programme with European/international funding to improve elements of the E&H information system and knowledge contained in it and to promote inter-country and inter-regional developments of the system to support its step-wise and consistent implementation.

• Set up an organisational framework (including mandate and responsibilities) to establish, co-ordinate and manage the entire process ensuring continuity and further development of existing mechanisms for regular reporting following common methods. The framework could have some of the following components which are not mutually exclusive:

2.1.1 Establish a Steering committee and working group of national and international representatives

Representatives of the European Commission (DG Env, DG SANCO, EuroStat), EEA, international organisations (WHO, UNECE, ...), MS and civil society could be nominated to form a European Steering Body.

Mandate:

(a) To develop a stepwise process of approval and selection of system elements2, The E & H info System elements are defined in common methodological guidelines (see point 3) and cover: data from monitoring and statistics, to indicators, assessment and reporting, as well as the mechanisms and methods for adjusting & updating, and accessing & communicating the information (see Diagram below and also WHO policy paper: Strengthening the policy-making base: Towards a shared information system to support environmental and health policies) the national policy needs and international requirements taken into consideration.

(b) To oversee the future development of the information base, to advise on current policy issues and make recommendations for changes to the reporting system.

2 System elements are defined in common methodological guidelines and cover: data from monitoring and statistics, indicators, assessment and reporting, as well as the mechanisms and methods for adjusting & updating, and accessing & communicating the information (see Diagram of EHIS in Section 3.2)

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(c) To plan the work on various system elements, coordinate relevant inputs of the partners, in particular of international bodies involved in the Environment and Health Information System process, and evaluate progress in implementation.

Options:

a. Different combinations of membership can to be considered

b. Different governance and reporting regimes (to whom does the steering committee report?)

c. Appointment of a secretariat (eg WHO, EEA, Commission)

Pros & cons:

This structure will promote cooperation between all partners concerned in the chain of activities from information production to use, promoting consistent, collaborative and coherent solutions. However, the size of the body and differences in the institutional conditions of the members may stymie effective cooperation. Danger of becoming very bureaucratic. Decisions about the different options should take these points into account as well as the source of funding to support this work.

2.1.2 Build up an Environment and Health Agency/virtual agency or expand the mandate of existing international organisations

Mandate:

(a) To gather [produce], disseminate information and report on the environment and health situation, its trends and future outlooks in order to monitor and eva luate the effects of policy and actions [with an emphasis on] the EU EH AP/ SCALE. (b) To manage data/indicator management and European assessments.

Options:

a. Create a EU Environment and Health Agency

b. Expand the mandate of existing EU bodies (eg EEA)

c. Create ‘virtual’ Agency of the relevant EU and international agencies and key players in generating data/ information on environment and human health

Pros & cons:

A new Agency i.e. Environment and Health Agency (EHA) could be set up to work in full conditions within a short time. It is an advantage to create an EHA in order both to show the priority of health effects related to environment and to show a clear distinction between already existing agencies within the EU-framework with the tentative touching interests of an EHA.

Existing bodies like the EEA already have large mandates, and it may but confusing or overwhelming to expand these too far. A collaborative arrangement between existing bodies, with a separately defined virtual or real entity/ies (eg steering committee and working group) may be more realistic, and cheaper and efficient to run in the short to medium term.

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2.1.3 Establish a network of collaboration between existing organisations

A network of environment and health information actors of national focal points, ‘focal points’ of the European Commission (DG SANCO, DG Environment, DG Research and EUOSTAT) and collaborating centres/ centres of excellence would improve data-flow and reporting.

Mandate:

To ensure regular data-flow and EH indicator reporting, establishment of standardised data exchange protocol and common reporting tools

Options:

a. Create a special network

b. Expand the EIONET

c. Select and `merge` elements of EIONET, EUPHIN, EUROSTAT, and APHEIS

Pros & Cons:

A network combined with an executive body (eg an Agency) can be effective when there is a need to combine and serve the needs of many different partners in different disciplines but can also be effective and decisive in prioritising and delivery (see EEA as an example). However there already exist many networks and additional one may be too much and lead to the retrenchment of a new group rather than the joining of existing groups.

2.1.4 Develop a shared information infrastructure

A shared information infrastructure, for use by all actors and built on existing technical capacities and expertise of the countries and international bodies will include the establishment of a network of collaborating national and international institutions with well-defined roles and responsibilities.

Mandate:

To elaborate the elements of the shared information system and in particular to further develop and manage the environment and health indicators, related data sets and the shared information infrastructure. The shared information infrastructure will enable use of data from existing international databases and facilitate access to the information, its use and re-use in national and international reporting.

Options:

a. Join forces with the environment shared information system of EEA’s EIONET

b. Join with the EU public health EUPHIN information system

c. Make separate system

d. Link all systems in one shared information system

e. Develop a set of projects establishing elements of the system for future linking

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Pros & Cons:

A careful feasibility study of the pros and cons needs to be carried out to understand better the issues at stake here. This should not hold up first steps which should be closely linked to existing systems. The commonalties in scope, coverage and objectives with the EEA EIONET environment shared information system argues for a close link and cooperation to be made here – economies of scale and the basic arguments behind a new E&H information system to encourage sharing information, integration of environment and health and between sectors and themes, providing common access to data and possibilities to link and inter-relate diverse data sets, all argue for the new system to be built on the existing EEA and WHO building blocks. Separate systems have the danger of leading to duplication and increased burdens for the countries with attendant higher costs and the possibility to lead to isolation and fossilisation. Building on existing systems and combining forces with existing experiences at international and national/regional levels will lead to a more dynamic overall process which can gain from the sharing of experiences.

2.1.5 Establish links to academic and policy communities

Mandate:

To support the systematic review of evidence relating to selected environment and health issues and the interventions to reduce health risks

Options:

a. Develop E&H expert network

b. Set up a E&H scientific review committee

c. Develop a collaboration between existing scientific institutions or networks to deliver the necessary reviews

Pros & Cons:

Danger of overlapping existing structures and overburdening existing scientists and experts. Opportunity to organise and focus expert knowledge to policy relevant activities. Need to make thorough review of needs, existing structures and opinions of clients and potential participants before embarking on one or other proposal.

2.1.6 Ensure national network representation

Nominate national representatives to ensure national network representation and to facilitate the development of a shared (and harmonised) information/reporting system at national level. National representatives should participate in European consultations and activities. They will ensure:

- national participation in European activities and consultations with the central institution/body/agency or committee

- the management of information flows - the coordination of national steering committees composed of environment, health and

statistical representatives and of all experts involved for further development of the entire process

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- coordination with local authorities for support and for implementation of policies by using inter alia the adopted indicators of the European E&H information system.

Mandate:

Establish one National representative for system elements and process management ensuring national and local implementation of organizational and technical infrastructure for the development of E&H information system.

Options:

a. Create a national representative of a “new” special network or of a new agency for E&H national information system;

b. Create a NFP of a multi- institutional steering committee responsible for system elements and process management.

Pros & Cons:

A single national representative will ensure a network linking to the European process, a reference point for local needs and implementation and the harmonisation process of all existing information systems and flows. The coordination of a steering committee will guarantee that all health and environmental issues will be brought jointly into the process. Centralizing system and process management will avoid problems of data comparability, availability and accessibility which, compared to the organizational needs of implementing a national centralized E&H information system, are costly to adjust.

2.1.7 Develop inter-country and inter-(euro)regional programmes to support the European E&H information system

To improve and implement elements of the European E&H information system in a step-wise manner relevant responsive to the needs at different levels, inter-country and inter-(euro)regional programmes are needed linked to and supporting the development and implementation of the overarching European E&H information system.

Activities will include funded projects for:

- inter-country projects for trans-boundary cooperation

- inter-(euro)regional development projects on common E&H issues and experiences (e.g. countries of Mediterranean area)

- projects for capacity building by twinning among regions or Countries to support mutual learning and the sharing of experiences improving the links between countries and with the European system and associated process.

Mandate:

Establish and implement an internationally funded framework programme to develop and run projects for an effective and consistent implementation of the E&H information system at international level which responds to European local needs and situations by promoting sharing and mutual learning among partners and with other national/regional processes.

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Options:

a. International funded framework programme lead by the EHIS Steering Committee with the participation of funding partners (Commission and the banks – EIB, EBRD, ADB & WB3) and international bodies and agencies (WHO, EEA, UNEP, UNECE, UNDP, UNESCO and OECD);

b. International funded programme lead by the European Commission with participation of the banks and international organisations, technically supported by eg WHO/EEA;

c. An international project preparation committee on the model of the PPC of the Environment for Europe (EfE) process4, with an international organisation acting as the secretariat and with the participation of all the relevant international organisations and banks

Pros & Cons:

A set of activities under an international umbrella would help in effective funding selection, since they are based on common well- tested and shared principles, for the benefits of implementation of European E&H information systems and its elements, such as filling network and territorial knowledge gaps as well as highlighting opportunities for synergies. The management of such a programme of activities will however need strong coordination and selection for it to be well targeted and effective.

Jobs and tasks of the organisational framework

o further develop harmonised E&H indicator set and framework (DPSEEA, MEME) o piloting o developing methodologies o facilitate development of shared and harmonised information/reporting system at

European level

o data management o process management o systems management o further develop harmonised analysis/reporting procedures o assessment (interpretation of the results) o evaluation of processes o publication of results o networking/communication member states o collaboration with international organisations o data collection for existing indicator/data sets

3 EIB – European Investment Bank; EBRD – European Bank for Reconstruction and Development; ADB – Asian Develoipment Bank; WB – World Bank. 4 The EfE Project Preparation Committee invested in actual projects to reverse deterioration of environemnt and health standards. For the EfE PPC’s final report for the 2003 Kiev Environment Ministers conference see http://www.unece.org/env/documents/2003/inf/inf.19.e.pdf

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2.2 Options for action on methodology

Development of methodological guidelines for indicators, assessment and reporting on EH. Such developments include the work on the definition of the policy-relevant indicators, and their feasibility and pilot testing in the Member States. The proposed indicators should initially be based on the existing data reporting systems and harmonised with the existing practices of information reporting. Both the broad WHO EH policy needs and the EU EH AP (SCALE) needs have to be considered. Methods for analysis, reporting and dissemination of the information should also be developed further, using the experience of WHO and EEA, and be harmonised with the national reporting practices and obligations. The information should be updated and the methodological guidelines adjusted on the basis of systematic reviews of the scientific evidence and policy, as well as from lessons learnt about the feasibility and relevance of the system. The guidelines should identify possible improvements and standardisation of the information most relevant for EH assessment. They should include recommendations for collection of new information and further development of harmonised instruments e.g. surveys. A conceptual view of the methodological approach produced for the WHO EHIS proposal is illustrated in the diagram.

Proposed diagram of EHIS

WHO European Centre for Environment and HealthWHO European Centre for Environment and Health

Environment and Health Information System –main system elements

Indicators Assessment& reporting

Adjusting & UpdatingPolicy review

HIA / SIA

Evidence review

Data gen

eration

Access & Communication

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2.2.1 Establish a harmonised EH Indicator set

There are numerous indicator sets available at local, national and international level, which contain one or more indicators relevant to environment and health (see Baseline-report for overview). Unfortunately, the indicators in the current interna tional databases and indicator sets vary in operational definitions (age, diagnosis), geographical scale and quality. In addition, countries have to report to different organisations on the same issues, but sometimes using slightly different indicator definitions. Thus, the development and use of a harmonised E&H indicator set to enhance data-comparability is recommended, taking into account different user needs at different levels. The development of a harmonised indicator set and data-warehouse of the underpinning data sets will enable bench-marking, save resources, stimulate better use of existing data, increase comparability of data and enhance easier and better communication to stakeholders and to the public and identification and prioritisation of research areas.

Work programme/Timeframe

A flexible approach towards implementation of EH indicators is proposed to enable the use of existing indicator sets, databases and current methodologies, while building towards the goal of a core set of harmonized indicators for the EU-region. While the strategy aims for continuous improvement and comparability among the indicators for the different member states, the approach (figure 2.1 in the first cycle does not insist primarily upon a common set of indicators and collection methods. Nevertheless, MS should intensify the work of implementation of EH indicators. Countries should not wait for an internationally harmonised set, but should continue to work from existing knowledge .

An important aspect is the flexibility for the countries involved to first recognize and then harmonize indicator sets, collection methodologies and infrastructure over time. The approach aims at providing each country answers to the question what the actual environment and health situation in their country is. This approach sets out the guidelines for answering this question along with asking for information about the collection methods and indicators sets.

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Figure 2.1. Strategy for the implementation and use of E&H indicator sets

Purpose To asses the quality of environmental health (adults & children) in Europe

Identify priorities & indicators E.g. Asthma, respiratory disease & air quality; water borne diseases; noise; housing, chemicals

Data collection Populate indicators in priority areas; begin with existing data

Review Review harmonized indicator sets in light of new and emerging environmental threats to public health, with special focus on children

Assess status Using populated indicators sets, assess the situation in each nation for each priority area. Including: •Exposure: ambient environment, community, home •Effects on health status •Actions undertaken

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3 Proposals for actions in SCALE with regard to data gaps

3.1 Introduction

A preliminary analysis of the available data for the four priority areas of the EH strategy indicates that the existing information is not sufficient enough to track the effect of possible preventive actions in these areas. Information needed for such evaluations is either lacking (eg in the case of policy evaluation), not harmonised (asthma, neurodevelopmental disorders) or not collected in a systematic way. When the health–environmental linkages are less well understood e.g. health effects of housing conditions or long-term exposure to chemicals the priorities, including research, are in identifying appropriate health outcomes and epidemiological measures as well as in harmonising the methods applied. In addition, the existing E& H information is not linked with data on other important risk factors, which is needed when analysing trends in environment and health.

In this chapter recommendations are given how to improve the current indicator sets and data-collections in order to better fit the information needs of SCALE. These are preliminary suggestions though, which need further discussion within the framework as described in chapter 2. The actions needed are:

• Develop and test the applicability and use of new indicators for the E&H arena (3.2- 3.6)

• Harmonisation of existing indicators (3.7)

• Develop tools for improved data collection and data- linkage (3.8)

3.2 Proxy indicators for exposure like distance of dwellings to roads, power lines, industry

EH indicators are currently provided for areas such as air pollution, water, noise where the evidence of health impacts is widely accepted and appropriate epidemiological measures for health impact assessment exist. However, for many exposures it is not feasible to get individual exposure data; thus, the use of more easily available so-called proxy indicators might be required in order to assess the exposure of larger population groups. An example would be the distance of dwellings/schools to major roads or power- lines lines. Recent studies indicate that distance to road is a good proxy for exposure to transport-related air pollution.

Pros and cons

Using these proxy indicators one has to be aware that they need to be validated and associations of health effects with those indicators have to be interpreted carefully when trying to assess cause-effect relationships. The costs of collecting this type of data will be low (especially as compared with exposure measurements), since they could become easily available through the, GIS-based JRC -project INSPIRE.

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3.3 Bio-indicators for emerging threats

Usually, environmental and health impacts are analysed and estimated through vertical toxicological analysis considering individual pollutants. This doesn’t take into account synergetic effects of exposure to cocktails of pollutant or exacerbation processes due to sequential exposure to different pollutants, etc… The use of indicator species/bioindicators, such as micro-organisms, sensitive animals and plants, eco-toxicological or veterinarian observations could be a good way to further understand the impact of multiple chemicals/pollutants in living bodies and measure synergetic effects of the exposure.

Such observations and researches, which provide results from cocktail environmental exposure and synergetic effects of low concentrations of individual pollutants or not yet identified pollutants, allow us to develop better focused and targeted strategies and actions and could also serve in early warning systems.

Pros and cons

When doing this, however, differences in exposure between the ecosystem and humans as well as other possible differences such as sensitivity and susceptibility, physiology and metabolism (toxico-kinetics and dynamics) have to be taken into account.

3.4 (Proxy)Indicators for health impacts and well being

In addition to information coming from surveys or physical examinations, information on the consequences of potential health impacts is very useful too. Long-term exposure to pollutants may lead to increased medical consumption (medication use, visits to physicians), increased absenteeism from school or work and may have impact on daily activities and quality of life. There are e.g. indications that exposure to certain pollutants is associated with an increase in medication use and school absenteeism.

Pros and cons:

Data for some of these indicators (such as sales and prescription of pharmaceuticals) are available, costs of collecting will be low. Eg in the Netherlands a national database is available which allows analyses on a regional level. The use of this type of indicators in the E&H field needs further testing and validation though.

3.5 Develop indicators for vulnerable groups and vulnerable periods in life

Lead concentrations in children’s tissues are a well-known example of an indicator in this category. Other examples are air pollutant levels for vulnerable groups like asthmatics.

A major problem is the limited number/quality of indicators reflecting exposure of the parents and/or children during preconceptual, prenatal, postnatal, and perinatal periods. Analytical measurements in individuals are presently costly. In addition, some of these indicators require formal consent of the participants as well as invasive techniques such as for blood sampling. Since exposure in the early periods of life is considered to be critical for many of the health endpoints currently under discussion, it is considered as a high priority to develop new/and or better indicators for this purpose which are also convenient for the child. Several environmental exposures such as lead and neurotoxic agents are known to exert specific

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health effects depending on age at exposure . Thus, environmental health indicators have to be targeted at the appropriate potential age-specific effects.

3.6 Develop methods to monitor and evaluate effect of combined exposures (e.g. integrating indicators)

Action: Further research and review of studies on effect of combined exposures.

Most health outcomes of interest for the environmental health issues are the result of combined exposure to several health determinants (combined exposures to physical pollutants, social conditions, lifestyle and genetic background). Nevertheless, the extent to which such exposure leads to greater health impairment is unclear.

Depending on the presence of other risk factors, some environmental factors may contribute differently to the process of the incidence of the health outcome, even if the relation between the factor and the effect is clearly causal. For example, the risk of lung cancer is much higher when exposure to radon and tobacco exposure occurs parallel.

The weight of evidence method has been incorporated into the US EPA’s guidelines and quantifies the extent to which the effects of a mixture of chemicals differ from the accumulated effects of the individual agents. Trials need to be conducted to see whether this method can also be applied for mixtures of other pollutants. Depending on the results of these studies methodology for future multi-exposure multi-effect monitoring, should be developed.

Today biomarkers for exposure exist that can discriminate between indoor, outdoor and occupational exposure, as well as food exposure. The validity and applicability of such integrating exposure biomarkers should be further explored in pilot studies.

Environmental public health policies will be more efficient if they can take into account interactions and multifactorialities. To guide such policies, environmental health monitoring systems in the future should include sets of exposure and sets of health effects as well as information on other health determinants, socio-demographic conditions and lifestyle.

The methodology as well as appropriate environmental health indicators for monitoring of the joint distribution of pollutants and effects needs further development. . Then, comparative risk assessment of these different pollutants will help decision-makers to establish priorities for preventive public health actions.

3.7 Further develop the use of aggregated indicators

Action: Implement and evaluate the use of aggregated indicators (e.g. DALYs, Cost of Illness) in E&H impact assessment and reporting.

The valuation of children’s health is considered as a relevant area for which validated indicators are still lacking. If indicators are available which assess the costs of the most important health effects as well as the potential benefits of specific measures targeted at those health effects, such indicators could be used by policymakers to appropriately allocate resources.

Prioritisation of E&H actions must take into account many factors (disease burden, political context, possibility of preventive measures, socio-economic impact) among which the disease

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burden is very crucial. Information on this last factor is very relevant and must be monitored by specific indicators. The impact of environmental related exposures on human health can take numerous shapes of various severity and clinical significance. Effects of air pollution for example range from increase in respiratory symptoms and hospital admission to mortality, while noise pollution is associated with annoyance, sleep disturbance and (perhaps) increased hospitalisation rates for cardiovascular diseases. These different health effects have to be compared with other health effects caused by competing decision alternatives (comparative risk assessment) or with costs of measures (costbenefit-analysis). Thus, a common metric for health outcomes that allows aggregating a wide range of health outcomes would enable decisions that are more informed. Experience with health metrics in environmental decision-support tools is limited to the use of years of lives lost (YLL), monetized estimates of health impacts and Quality Adjusted Life Years (QALYs) or Disability Adjusted Life Years (DALYs). All these studies used human health metrics in order to aggregate different health outcomes in one dimension so as to make them more comparable and interpretable.

Pros and cons

The estimation of the disease burden attributed to risk factors has the potential that policy can directly act on risk factors. This means, however, that one needs insight in the causal web and that the results should be integrated into wider frameworks for preventive action. It will allow the evaluation of possible trade-offs among specific health targets pertaining to a specific policy eg air pollution vs accidents. An additional positive aspect of integrated health impact assessments is the possibility of not overlooking the ‘side effects’ resulting from a policy addressed to a specific issue, allowing to maintain control on what would happen not only in terms of eg emission reductions but also in terms of road safety/noise. For planning and policy-evaluations it may be preferable to carry several dimensions though and to make the reduction to a single dimension at the latest stage.

The strength of evidence for environmental health problems is variable and sometimes low. For future disease burden calculations a “sufficient level of evidence” should be defined (Eg as outlined by IARC or EPA) and uncertainties specified. On the other hand, while scientific evidence for environmental epidemiology is still sparse, decision-makers should avoid considering only those determinants of health that are adequately quantified (Pruss et al, 2001). Currently, WHO-Geneva is further developing the evidence base for environment-related disease burden estimation, describing the methodology and models for different risk factors (www.who.xx).

3.8 Harmonisation of existing information and indicators

Action: Harmonise existing indicators with regard to information needs of SCALE

• Indicators for child neurodevelopment are not well developed on a population basis. Information collected during regular examinations regarding the development and behavioural performance of the children within the health care system should be standardised in the EU and performed at defined ages of the children. Better indicators, less costly than individual biomonitoring, of exposures via the mothers during pregnancy and lactation need to be developed.

• For respiratory health (in particular asthma/asthmatic complaints) diagnostic criteria differ between countries. Agreement is needed at a European level on the definition of asthma cases, and indicators used (prevalence of asthma, of hospitalisation for asthma, of deaths linked to asthma). Since first symptoms in most of the children occur already

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at an age below 4, indicators should be available age-specific, for younger children even related to quarters of a year. In order to address factors which may be relevant with regard to exacerbation of asthma, indicators should also reflect the severity of asthma symptoms.

• Perinatal/infantile conditions like hypospadia and cryptorchidism (perhaps related to EDCs) are currently not accurately measured. Standardisation of diagnostic criteria and month of age when respective examinations are performed is necessary on a EU-wide basis in order to get comparable data. Measurements of pharmaceuticals in the environment should be considered because of potential human effects, for example hormonal effects of contraceptives.

3.9 Improve data –collection and data-linkage methods

Action: Adjust ongoing international surveys (eg HIS/HES as part of the Health Monitoring Programme of the EU)) to better fit the information needs of SCALE.

For some areas, e.g. housing , harmonised data collection methods are missing or not used. In addition, an instrument needs to be developed which measures quality of life of children in relation to their environment. For noise, harmonised exposure metrics and exposure calculation methods are proposed in a EU-framework and standardised methods to assess annoyance have been proposed by ISO. Further development of harmonised survey methods within an international framework should be reinforced.

Action; Enhance data-linkage of existing datasets

An important missing link in the data-analysis is the lack of spatial data regarding location of e.g. sources of pollutants, socio-demographic data and lifestyle (e.g. food) habits which could be delivered from other databases (e.g. Eurostat New Chronos) and projects (eg INSPIRE, see chapter 4).

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4 Proposals for improved monitoring and health impact assessments

4.1 Develop mechanisms for sharing experiences and improving integrated assessments

Actions:

European Commission and MS should endorse mechanisms together with actions to develop integrated assessment methodology framework that will allow the adoption of

• jointly working process incorporating environment and health professionals in an early phase of e.g. residential developmental and infrastructure planning/transport and land use plans. An option is to establish a E&H expert team link to the local EIA committee.

• a E&H integrated assessment-tailored training programme on E&H issues and methodology for assessing health impacts and externalities of health determinants;

Environment and health policies should integrate information on interactions and multiple factors encompassing the broad range of health determinants, ranging from pollutants to economical, socio-demographic conditions and lifestyle. Many of these determinants rely on a wise implementation of environmental policies (e.g. management of urban areas, transport, energy, land use and water resource management) that should take in account public health issues.

Integrated assessment, that is the integration of health, environmental and economical aspect in assessment processes, is quite promoted by Community policy acts for Environmental and Health policy as well as in the SCALE-strategy. Although there are many national and international experiences on the issue, there is still a lack of a shared (institutional) european framework and methodology for E&H integrated assessment to be used by health and environmental operators on an ordinary basis,

Indeed a European governance assuring rational, informed political and social decisions on such complex, long-term, and uncertain issues as environment and health problems should rely on national/local mechanism to integrate, reconcile, organize, and communicate knowledge across domains. This will also allow a more informed European monitoring of E&H issues ( e.g. health determinants related to water resource management in south and north Europe) and a real constructive implementation of E&H action on local level

Benefits can be gained by joint involvement of trained health and environmental professionals in an early phase of the ordinary assessment and planning processes. In local development plans this rarely happens, if ever.

An appropriate training of involved E&H professionals for integrated assessment procedures and tools should be developed though. On local settings health professionals are not familiar with environmental monitoring procedures, environmental operators are not familiar with health risk assessment procedures, health determinants or health priorities linked to environmental policies. Training costs can be supported by local authorities.

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4.2 Develop tools for improved linkage of EH data with geographical information

Action: Develop tools for improved linkage of EH data with geographical information Enhance possibilities for linkages of spatial data (eg from INSPIRE) with health and lifestyle data

Linking E&H indicators with data on pollution sources using geographical information systems is a good way to integrate environmental and health information and activities responsible for potential risks. The Global Monitoring for Environment and Security (GMES) initiative of the commission will bring an understanding of environmental factors potentially having health effects. In order to generate synergies, facilitate the sharing of data and methodologies and increase the understanding of the environment and health relationship, some link should be established between health data with environmental and geographical data. This will allow a picture of the demography and exposure patterns contributing to studies on adverse health effects (cf. INSPIRE initiative, which is a multi- thematic and multisectoral initiative).

However, when studying spatial disease patterns in relation to e.g. the location of certain sources without taking into account individual risk factors (life style and SES) one has to be aware of the so-called ecological fallacy (false associations). These type of studies when using aggregated data have an important sentinel function, but warrant further more in-depth studies. Also, research on methodological developments for mapping of environmental health indicators should be encouraged.

4.3 Biobanks for assessment of long-term effects and multicausality

Establishments of biobanks are important tools for making retrospective studies and research. Existing European biobanks must be surveyed, and existing samples should be made available for scientist in a coordinated way. Analytical chemistry and molecular biology are developing fast and have a great potential to identify new health problems, study long term exposure patterns and multicausality. Biobanks are relevant for most of the priority areas within the SCALE initative. The ethical issues and confidentiality problem however must be addressed.

4.4 Proposal to improve current monitoring systems

In E&H monitoring systems, the environment and health factors must be measured and analysed

a. with respect of time lags. Time series analysis can be convenient for short-term effects without too much confounding at this scale (ex : urban air pollution and specific mortality and admissions to hospital)

b. at specified sites that are geographically representative of the problem (concerning exposure to a pollutant, or the population targeted)

c. in relation to defined populations with period of exposure.

d. with a quantitative understanding of the expected population attributable disease fraction

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4.5 Evaluate present scientific information and literature for new E&H indicators.

Action: results from qualitative good epidemiological studies regarding the association between environmental exposures and health impacts should be fed directly in the E&H information process (see chapter 2), thus ensuring that relevant priority areas are covered in time.

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5 Proposals to support and facilitate decision-making and track effects of preventive actions

5.1 Indicators for policy performance

Action: To assess the effectiveness of a new environment and health policy step by step tracking of the process is needed. Indicators to track and evaluate policy performance need to be developed already at the stage of policy development. There is a great need to develop distance-to-target indicators within the environment and health arena.

Examples of such policy efficiency indicators are:

- risk perception before and after an information campaign. (e.g. health risks due to exposure to radon)

- The level of compliance to action recommendations or regulations, or the exposure levels before and after action (for example % of houses with high levels of radon detected and/or remediated in an area)

- Co-exposure to other risk factors. Taking into account other risk factors is important to assess correctly the success of action (e.g. surveys showed that the compliance to action concerning radon levels in houses is more important on population of old non smokers than in families with children, young smokers).

- Indicators of health (final step) are also useful. Their relevance is obvious for short term effects (for example number of admissions in the hospital for cardio-vascular diseases related to urban air pollution). It is also very important for long term and multifactorial effects (tendency of lung cancer linked to addiction to smoking, exposure to radon, and asbestos…)

- At the European level indicators allowing comparison between policies from each country and their progress are important.

5.2 Develop tools to enhance informed decision-making

Action: Further develop and test tool for balanced decision-making.

Policymakers must set priorities and have to decide about very different issues with varying health impacts and uncertainties (ranging from asbestos to e.g. power lines). A transparent framework is needed which must ensure that all relevant aspects of the risk assessment are being considered in the discussions with different stakeholders.

The framework should be:

• A starting-point for balanced and transparent decisions in health and environment by policy makers

• Based on recent scientific evidence

• A good description of recent knowledge on health and environment

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• A sound basis for decision-making by authorities

• Enable consensus between different stakeholders (same issues considered)

An example of such a framework is a checklist recently developed in the Netherlands (V Bruggen et al, 2003). This checklist is subdivided in five issues: Magnitude of health effects (results health impact assessments), severity of health effects and potential risk groups, perception of risk, possibility of interventions and cost effectiveness of measures. For every key issue several questions have been developed for which information has to be provided. The checklist has been used in priority setting at national level and was also to be considered useful in discussions with stakeholders at a local level. The costs involved in further developing and testing this or comparable tools (e.g. developed by WHO) at international level is low. Mechanisms need to be developed though to involve trained professionals to fill in the checklist at (inter)national level, involve stakeholders (decision-makers, industry, NGOs) and share results. Finalised checklists or factsheets can be made available via a shared electronic information system (see chapter 2 and 6).

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6 Proposals for improved communication and education

6.1 Develop tools for awareness raising and improved communication to the different target communication audiences

Action: Improve communication with stakeholders at international level by developing a combination of electronic information systems, website, fact-sheets and periodic newsletters and indicator-based reports. Electronic information systems could be set up to (a) give periodic feedback and update mechanism among Member States and (b) to raise awareness among eg health professionals.

The Aarhus convention (AC) was adopted through EU parliament and implementation is obligatory for MS. The main objectives of AC is free access to environmental data, public participation in decision-making and access to justice in environmental matters. It is very important to inform, educate and involve public, industry and NGO’s in all environmental procedures to reach better results for protecting human health, environment and natural resources.

Reliable E&H indicators are necessary to increase the understanding between environment and health and will allow the development of good quality training programs.

Based on reliable E&H indicators, the message can be adapted to any public (politicians, public, families, etc…) depending on the indicators used, which will allow the different E&H actors to:

• raise public awareness, educate people and ensure more efficiency while implementing actions,

• narrow the gap between environmentalists, health actors and the public through the development of some common language and gain trust from all parties … which can be more than useful in crisis situations,

• validate knowledge through the use of validated and standards indicators through comparisons with other health threats and through networking,

• allow politicians to develop preventive policies, programs and actions plans and therefore be more cost-effective,

• increase understanding, transparency and visibility between all stakeholders (public, NGO’s, national and local authorities, experts, local associations) in decision making processes.

The information provided by the E&H information system to its different target audiences (decision-makers, environment and health professionals, the public) should be clear and easy-to-use and should take into account their specific information needs in terms of content and form.

For decision-makers, learnings from the third phase of the APHEIS monitoring programme on air pollution and health (www.apheis.net) show that the information should be processed at virtually every step in the policy-making process. By processed, we mean the information has to be distilled, interpreted and framed to meet various policy needs –political, social and economic, among others. And at the end of the chain, complex scientific information has to be boiled down to just a few pages and key messages that reach the desk of the policy-makers

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themselves. Based on the research conducted, this general process seems to apply on the local, national and European levels of decision making (see figure below).

Besides working on the ‘distillation’ of the scientific content, communications tools should be developed according to the specific socio-cultural context in which they will be used and, to really reach simultaneously local and European decision-makers and to ensure the maximum efficiency of our E&H information system, the communication tools should be built directly in the different languages of the European Union. This also apply when communicating with environmental and health professionals and the public.

Then, preparing communications tools for decision-makers, environment and health professionals, and the public should be considered as a crucial task of the E&H information system, and it needs the help of communications experts.

Mandate:

The European Commission and Member States should endorse recommendations and actions to ensure high-quality communication from the E&H information system through a thorough Environment and Health Communications’ strategy addressed towards its different target audiences and built with the qualified knowledge of communications experts at the European and MS levels.

How information flows in the decision-making process

Information usually gets processed when passed on

Apheis Information

system

Scientists(direct scientific users)

Policy advisors(policy pass-on users)

Scientific committees(scientific pass-on users)

Policy makers(policy pass-on users)

Information distilled, interpreted, excerpted

Source: Saklad Consultants for Apheis 3

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6.2 Promotion of environmental health/environmental medicine

6.2.1 Promote Environmental Health /Environmental Medicine training & raise awareness for quality requirements at involved parties/professionals

• strengthen environmental health/medicine in the medical curricula (university, other health professions)

• strengthen interdisciplinary training programmes

• develop training programmes for teachers in day care centres and schools

• highlight good research programmes for know-how transfer

6.2.2 Promote harmonisation of environmental health/medicine and its organisation and structure throughout Europe

• harmonised definition of Environmental Medicine throughout Europe

• develop harmonised degrees in Environmental Medicine

• harmonised organisation and structure on governmental and regional level, e.g. one ministry taking the key responsibility for environmental health/medicine issues

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7 Annex: Reporting formats

Option 3.1. Preliminary statement : The Action Programme 2004-2010 should: § Endorse well-coordinated activities to establish and implement environment and health indicator reporting and

assessment serving the SCALE needs and applying standardised methodological guidelines § Set up a [European and national] decision-making process on the progressive development and implementation of

the information system. § Endorse a framework programme with European/international funding to improve elements of the E&H

information system and knowledge. § Set up an organisational framework (including mandate and responsibilities) to establish, co-ordinate and manage

the entire process. The framework could have several components which are not mutually exclusive. (working group: EH Indicators…….. Name: Dafina Dalbokova/ David Stanner)

Option for action: Establish an organisational framework for indicator development, management and use in the European Region What is happening just now (describe the current situation qualitatively and quantitatively where possible)?: What is the problem (qualitatively and quantitatively where possible)?: How does this option contribute to the goals of the Strategy ? 1) to the European Integrated Environment & Health Monitoring and Response System :

– Generate synergies and facilitate the sharing of data and methodologies – Increase the understanding of the environment and health relationship – Improved data availability, accessibility, comparability – Enhanced exchange of information

2) to improve public health with respect to environmental risk factors 3) to the research agenda 4) to raise awareness, to educate An organisational framework would contribute to the European Integrated Environment & Health Monitoring and

Response System as a whole via its mandate to: • Develop a stepwise process of approval and selection of system elements covering data from monitoring and

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statistics, to indicators, assessment and reporting, as well as the mechanisms and methods for adjusting & updating, and accessing & communicating the information the national policy needs and international requirements taken into consideration.

• Oversee the future development of the information base, to advise on current policy issues and make recommendations for changes to the reporting system.

• Plan the work on various system elements, co-ordinate relevant inputs of the partners, in particular of international bodies involved in the Environment and Health Information System process, and evaluate progress in implementation.

Main stakeholders affected by the option and how they are affected: National institutions

International Organisations e.g. EEA, WHO, EUROSTAT

European Comission e.g. DG Sanco, DG Environment

benefits, advantages (qualitative description should be provided of all impacts, along with either quantification of the impacts or examples and underlying assumptions. For example, how will the impacts relate back to the problem identified above?): Financial Health environmental Social Other Costs, disadvantages (qualitative description should be provided of all impacts, along with either quantification of the impacts or examples and underlying assumptions.) Financial Health environmental Social Other Alternative ways of achieving the same objective, and their pros and cons relative to the option chosen. 3.1.1 Establish a Steering committee and working group of national and international representatives This structure will promote cooperation between all partners concerned in the chain of activities from information production to use, promoting consistent, collaborative and coherent solutions. However, the size of the body and differences in the institutional conditions of the members may

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stymie effective cooperation. Danger of becoming very bureaucratic. 3.1.2 Build up a Environment and Health Agency/ a "virtual" agency or expand the mandate of existing international organisations A new Agency i.e. Environment and Health Agency (EHA) could be set up to work in full conditions within a short time. It is an advantage to create an EHA in order both to show the priority of health effects related to environment and to show a clear distinction between already existing agencies within the EU-framework with the tentative touching interests of an EHA. Existing bodies like the EEA already have large mandates, and it may but confusing or overwhelming to expand these too far. A collaborative arrangement between existing bodies, with a separately defined virtual or real entity/ies (eg steering committee and working group) may be more realistic, and cheaper and efficient to run in the short to medium term. 3.1.3 Establish a network of collaboration between existing organisations A network combined with an executive body (eg an Agency) can be effective when there is a need to combine and serve the needs of many different partners in different disciplines but can also be effective and decisive in prioritising and delivery (see EEA as an example). However there already exist many networks and additional one may be too much and lead to the retrenchment of a new group rather than the joining of existing groups. 3.1.4 Develop a shared information infrastructure A careful feasibility study of the pros and cons needs to be carried out to understand better the issues at stake here. This should not hold up first steps which should be closely linked to existing systems. The commonalties in scope, coverage and objectives with the EEA EIONET environment shared information system argues for a close link and cooperation to be made here – economies of scale and the basic arguments behind a new E&H information system to encourage sharing information, integration of environment and health and between sectors and themes, providing common access to data and possibilities to link and inter-relate diverse data sets, all argue for the new system to be built on the existing EEA and WHO building blocks. Separate systems have the danger of leading to duplication and increased burdens for the countries with attendant higher costs and the possibility to lead to isolation and fossilisation. Building on existing systems and combining forces with existing experiences at international and national/regional levels will lead to a more dynamic overall process which can gain from the sharing of experiences. 3.1.5 Establish links to academic and policy communities Danger of overlapping existing structures and overburdening existing scientists and experts. Opportunity to organise and focus expert knowledge to policy relevant activities. Need to make thorough review of needs, existing structures and opinions of clients and potential participants before embarking on one or other proposal. 3.1.6 Ensure national network representation A single national representative will ensure a network linking to the European process, a reference point for local needs and implementation and the harmonisation process of all existing information systems and flows. The coordination of a steering committee will guarantee that all health and environmental issues will be brought jointly into the process. Centralizing system and process management will avoid problems of data comparability, availability and accessibility which, compared to the organizational needs of implementing a national centralized E&H information system, are costly

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to adjust. 3.1.7 Develop inter-country and inter-(euro)regional programmes to support the European E&H information system A set of activities under an international umbrella would help in effective funding selection, since they are based on common well-tested and shared principles, for the benefits of implementation of European E&H information systems and its elements, such as filling network and territorial knowledge gaps as well as highlighting opportunities for synergies. The management of such a programme of activities will however need strong coordination and selection for it to be well targeted and effective. Is further analysis needed?: What would be the work programme?:

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Option 3.2 Preliminary statement : At present common priority areas are chemical, microbiological and physical risk factors in

the ambient and indoor environment. (working group: EH Indicators…….. Name: Jürgen Thelen)

Option for action:

7.1.1 Selection of priority areas (Air Quality, Water Quality, Noise, Chemical Safety, Food Safety)

What is happening just now (describe the current situation qualitatively and quantitatively where possible)?: The selection of priority areas is a major requirement for the further progress towards the development and use of E &

H indicators. According to the common understanding, indicators should help to identify priority areas, but the selection of these areas has to follow scientific evidence and must be accompanied by a political process. Recent assessments of the burden of disease caused by environmental health risks indicate that air pollutants and noise exposure are among the most important environmental factors that contribute significantly to the risk for cardiovascular diseases. These diseases are the most common in the European Union. Even though the contribution of environmental factors to these diseases is only minor compared to the more pronounced impact of lifestyle (e.g. nutrition, physical activity and health behaviour) and social conditions (e.g. ageing of the population, social inequality) their contribution is significant. The relationship between recent cancer rates and the exposure to environmental contaminants e.g. dioxins or pesticides is less evident. However following the precautionary principle selected chemicals should be covered by indicators that can be derived from human or species biomonitoring (e.g. heavy metals, POP, Pesticides). Although environmental health issues in the MS might differ considerably, the identification of priority areas that are important for all MS posed the possibility to test the feasibility and the added value of E & H indicators. Because issues of driving forces of environmental health risks like mobility are also covered by other indicator initiatives (e.g. TERM) it is recommended to focus on indicators that describe certain exposures in relationship to the affected population. These exposure indicators can be combined with the results from health impact assessment if available.

What is the problem (qualitatively and quantitatively where possible)?: As demonstrated by the indicator based pilot study report of the WHO E & H Indicator project the exposure to

chemical, microbiological and physical pollutants/risks is a priority in most of the MS. It is proposed to identify indicators that define population exposure with respect to air pollutants like PM10, NO2 and Ozone.. The health risks from noise exposure and contamination of drinking water and recreational water should also be regarded. For the latter two reliable exposure assessments currently exist only for a number of MS. The description of noise annoyance as a

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proxy for noise exposure should be considered until the reporting obligations connected with EU directive on environmental noise (2002/49/EC) becomes effective and reliable data for noise exposure is not available from other sources.

How does this option contribute to the goals of the Strategy ? 1) to the European Integrated Environment & Health Monitoring and Response System :

– Generate synergies and facilitate the sharing of data and methodologies – Increase the understanding of the environment and health relationship – Improved data availability, accessibility, comparibility – Enhanced exchange of information

2) to improve public health with respect to environmental risk factors 3) to the research agenda 4) to raise awareness, to educate 1) Selection of indicators for priority areas is a result of different considerations. On the one hand the data availability

for many environmental health risks is limited on the European level and the further extension of data collection is limited due to limited administrative and financial resources. Europe-wide only a few good examples for the definition of data quality criteria and harmonised data flows exist. These data flows cover environmental data that is collected by MS due to reporting obligations contained in EU-directives. One of these Examples is the air quality database AIRBASE, that is hosted by the European Topic Centre for Air Quality of the EEA at the RIVM. Although MS are asked to report their air quality measurement data together with additional reference to the population affected, this information is not given in most of the cases. It would be worthwhile to reinforce the efforts to gather this information from the MS.

2) Indicators for exposure to environmental risk factors provide the opportunity to improve public health by demonstrating the effectiveness of regulatory measures and by identifying regions that are particularly affected.

3) A Europe-wide and regularly performed assessment of exposure to air pollutants and environmental noise and the assessment of the associated burden of disease could raise the awareness of the population and stakeholders.

Main stakeholders affected by the option and how they are affected: EEA; WHO; NFP EIONET, Eurostat

Airbase managers; Waterbase managers National Focal Points of EIONET; national and community administrators of air quality measurement networks

benefits, advantages (qualitative description should be provided of all impacts, along with either quantification of the impacts or examples and underlying assumptions. For example, how will the impacts relate back to the problem identified above?): Financial Improvement of existing database; Use of existing Reporting tools (DEM); Possibility to implement an interface

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between AIRBASE and AirQ for computer assisted analysis and assessment. Health The evidence for the health effects related to the exposure to air pollutants (e.g. PM10) has been shown by a number of

good epidemiological studies. The reduction of population exposure to air pollutants (ambient and indoor) would contribute to a gain in life expectancy and theoretically in a reduction of the risk for cardiovascular diseases. Integrated assessment of the health impact of air pollutants could strengthen the efforts to further reduce air pollutant emissions by demonstrating the effect of administrative measures (e.g. incentives for the use of particulate filter, implementation of taxes for fossil fuels, incentives for the use of public transportation systems or human powered mobility).

environmental Improvement of data quality in AIRBASE for exposure assessment and health impact assessment (HIA); Combined Exposure and Health assessments can demonstrate the effect of political measures aiming at the reduction of undesirable pollutant levels.

Social Ambient and indoor air quality is affecting the health of everybody. European regulations concerning air quality exist and contain reporting obligations. The residents of urban areas and agglomerations are exposed to higher levels of ambient air pollutants compared to the population in rural areas. Children are a vulnerable subgroup because of their higher breathing frequence and their higher minute volume.

Other Costs, disadvantages (qualitative description should be provided of all impacts, along with either quantification of the impacts or examples and underlying assumptions.) Financial Efforts of the local administrators of air quality measurement networks to reach consensus about the designation of

reference population; financial ressources to establish the interface between AIRBASE, population data and AirQ for an automated analysis of the data.

Health Immediate health gains cannot be expected in areas where ambient air pollution is already considerably low, extension of health statistics for respiratory morbidity would

environmental Social Other Alternative ways of achieving the same objective, and their pros and cons relative to the option chosen. Is further analysis needed?: Further analysis is needed to improve the data quality of AIRBASE and to integrate the exposure assessment in the

existing indicator contained in the set of structural indicators of the EC (en041, en042 http://europa.eu.int/comm/eurostat/newcronos/queen/display.do?screen=welcome&open=/&product=STRIND_ENVIRO&language=de&depth=2 ). These indicators should be merged with the indicator exposure to air pollutants (Air_Ex 1) which will be

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provided as a outcome of the DG Sanco project “Development of environment and health indicators for the European Union”. The possibility of providing an interface between AIRBASE and the WHO air quality assessment tool AirQ should be considered. The structural indicators on traffic performance (en031-en034) can be used to identify trends for upstream determinants in the context of the European Community. The Drinking water directive (98/83/EC) defines reporting requirements and formats which should be examined for their potential use for indicator based reporting and assessment. The information that will be provided is useful to get a complete picture of the quality of the drinking water supply in the MS. Moreover the reporting requirements contain the population served by certain suppliers which enables for population based exposure analysis in the case of derogation. The information on microbiological drinking water contaminants could be combined with the data from national notification systems for infectious diseases. A common set of specific water-borne diseases should be defined in order to facilitate the analysis of infectious diseases surveillance data. The directive on environmental noise (2002/49/EC) requires competent authorities in Member States to draw up "strategic noise maps" for major roads, railways, airports and agglomerations, using harmonised noise indicators Lden

(day-evening-night equivalent level) and Lnight (night equivalent level). These maps will be used to assess the number of people annoyed and sleep-disturbed respectively throughout Europe. These assessments could be used to perform health impact assessments for noise exposure on a European level.

What would be the work programme?: Specification of data requirements for HIA for long-term exposure to air pollutants and environmental noise.

Thoroughly verification of data gaps in AIRBASE for HIA and reinforcement to gather this data from MS. Development of procedures to examine the data delivered under the drinking water directive for population based assessment of exposure to contaminants in drinking water. Definition of water-borne diseases related to the consumption of drinking water. Development of procedures to use the data delivered under the directive on environmental noise for population based assessment. Identification of epidemiological measures to calculate the disease burden related to the exposure to environmental noise.

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Option 3.3 Preliminary statement :

(working group: E&H Indicatiors Name:Marie-Christine De Wolf……………………) Option for action: Tools for awareness raising and improved communication to the public INDICATOR SPECIES/BIOINDICATORS

The use of indicator species/bio- indicators, such as micro-organisms, sensitive animals and plants, eco-toxicological or veterinarian observations is a good way to further understand the impact of multiple chemicals/pollutants in living bodies and measure synergetic effects of the exposure.

What is happening just now (describe the current situation qualitatively and quantitatively where possible)?: - Missing standards, protocols, legislation and frameworks

- The environmental and health impacts are analysed and estimated through vertical toxicological analysis considering pollutants individually. This doesn’t take into account synergetic effects of exposure to cocktail of pollutant or exacerbation processes to sequential exposure to different pollutants, etc…

- The impact of multiple pollutants exposures is registered through long term health observations (cancer, endocrine disruptors, etc…).

- Part of the population through living habits, etc… introduce some bias in many studies trying to understand some environmental impact on the health of the population.

What is the problem (qualitatively and quantitatively where possible)?: - Through the existing protocols and legislation, we have long term feedback of health impact resulting from

cocktail environmental exposure and synergetic effects of even low concentration of individual pollutants or not yet identified pollutants. In order to ensure the confirmation of potential environmental and health risks, results appear when health impacts cover already an important fraction of the population. For the present time we wait until cancer, respiratory or others diseases increases trends are confirmed resulting from environmental exposure. The observations of sensitive species, indicator species could allow us to highlight the potential risks in a shorter period of time and integrate the response of living bodies to cocktail environmental exposure.

- Health cost impact: resulting from the long term feedback (cf. see above), most of the actions undertaken are corrective actions which entails increasing health costs.

How does this option contribute to the goals of the Strategy ? 1) to the European Integrated Environment & Health Monitoring and Response System :

– Generate synergies and facilitate the sharing of data and methodologies – Increase the understanding of the environment and health relationship – Improved data availability, accessibility, comparability

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– Enhanced exchange of information 2) to improve public health with respect to environmental risk factors 3) to the research agenda 4) to raise awareness, to educate - The observation of sensitive species/bio- indicators (micro-organisms, plants, animals) would increase the

understanding of the environment and health relationship in a shorter period of time than existing chemical and biological analysis, which even don’t respond to synergetic effects.

- The use of sensitive species/bio-indicators would also improve in certain circumstances data comparability by eliminating some bias introduced by living habits.

- By allowing to get information in a shorter period of time, the use of such indicators would allow to evolve towards preventive action plans rather than corrective actions.

Main stakeholders affected by the option and how they are affected: * The European Commission should allocate means in order to facilitate research studies to:

- identify and validate sensitive species/bio- indicators; - validate the protocols for observations, registration and collection of information in order to increase the

potential of synergies, facilitate the sharing of data and their comparability and create expert basis for legislation;

- facilitate the exchange of information through scientific networks (universities or professional networks (veterinarians, agriculture engineers, biologists, eco-toxicologists, epidemiologists, etc…));

- facilitate and encourage the development of transversal studies in order to increase the understanding of the environment and health relationship;

- according to this validate information, encourage the development of preventive action programs and strategies.

Member States will ensure that: - validated sensitive species are implemented; - local professionals are trained for validated observations; - means are allocated to allow exchange of validated observations; - means are allocated to develop and implement preventive actions. -

Research Institutions will need to : - identify and validate sensitive species; - develop expert basis for standardisation for reporting results and basis for legislation;

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- validate the protocols for observations, registration and collection of information in order to increase the potential of synergies, facilitate the sharing of data and their comparability;

- exchange the results of their observations through scientific networks (universities or professional networks (veterinarians, agriculture engineers, biologists, eco-toxicologists, epidemiologists, etc));

- validate the interpretation and extrapolation of the results of the observations and researches of the set of validated bio- indicators in the understanding of the environmental impact of cocktail environmental exposure and synergetic effects of even low concentration of individual pollutants or not yet identified pollutants on human beings;

- develop studies (horizontal/integrating studies) that allow, through the observation of the sensitive species/bio-indicators, epidemiological studies, veterinarian observations, etc , a better understanding of the physiological processes and the potential impact of the environmental pollution on human beings;

- translate results into response system/policy.

benefits, advantages (qualitative description should be provided of all impacts, along with either quantification of the impacts or examples and underlying assumptions. For example, how will the impacts relate back to the problem identified above?): Financial - Reduced health costs by increasing the potential for the development of preventive action plans (see above

“what is the problem”).. - The observa tion and researches of bio- indicators might cost much less than detailed chemical and biological

analysis, even more when we don’t know which chemical we are looking for. - Such observations and researches, which provide results from cocktail environmental exposure and synergetic

effects of even low concentration of individual pollutants or not yet identified pollutants, allow us to develop better focused and targeted strategies and actions. This will avoid loss of huge amounts of money for the implementation of non efficient actions.

Health - Increased understanding of the impact of cocktails of pollutants in the body and synergetic effects on the health (ex. simultaneous exposure to external air pollutants and indoor pollution; impact of a combination of ground/water and air pollution on the health);

- Reduced time scale to increase the understanding of the impact cocktails of pollutants in the human beings; - More potential for the development of preventive actions plans.

environmental More data on the state of the environment from different natural resources (ground and surface water, soil, air, …) which will lead to the development of preventive actions plans and strategies and more focused and targeted (and therefore efficient) programs and sanitation projects.

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Social Bio- indicators can be considered as a good tool for education, communication, awareness raising and public participation in the Environmental and Health management process. It is also a good tool to induce networking between NGO’s, children, experts and all social actors.

Other Costs, disadvantages (qualitative description should be provided of all impacts, along with either quantification of the impacts or examples and underlying assumptions.) Financial Necessary means for the development and implementation of the option (see above). Health None environmental None Social None Other Alternative ways of achieving the same objective, and their pros and cons relative to the option chosen. Is further analysis needed?: Cf. role of Research institutions What would be the work programme?: See above

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Reporting format for options for actions

Option 3.4 Preliminary statement : (working group:EH Indicators…….. Name: Dirk Pallapies, Monica Nordberg

Option for action: 7.1.2 Develop indicators for vulnerable groups

e.g. Indicators for exposure during preconceptual, prenatal, postnatal, peri-natal period including pregnancy

What is happening just now (describe the current situation qualitatively and quantitatively where possible)?: What is the problem (qualitatively and quantitatively where possible)?: Recent reports showed that intake of cadmium in infants may be close to present PTWI for cadmium due to high

concentrations of cadmium in infant formulas. Neurotoxic effects due to prenatal exposure to cadmium via intake of mothers milk in children indicates that risk assessment should be performed differently in children than in adults where it is based on kidney failure. This might also be relevant for other chemical compounds.

For children specific indicators indicating the critical effects in children should be used. Further cooperation with diseases and biomonitoring groups should be taken. For cocktail effects, combined effects and cumulative effects presently no ind icators are available.

How does this option contribute to the goals of the Strategy ? 1) to the European Integrated Environment & Health Monitoring and Response System :

– Generate synergies and facilitate the sharing of data and methodologies – Increase the understanding of the environment and health relationship – Improved data availability, accessibility, comparability – Enhanced exchange of information

2) to improve public health with respect to environmental risk factors 3) to the research agenda 4) to raise awareness, to educate Increase the understanding of the environment and health relationship Main stakeholders affected by the option and how they are affected: EU, WHO, National Agencies benefits, advantages (qualitative description should be provided of all impacts, along with either quantification of the impacts or examples and underlying assumptions. For example, how will the impacts relate back to the problem identified above?):

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Financial Vulnerable/sensitive groups Health Provide information on exposure and bodyburden environmental Give priority to fetus and nursing infant, women in fertile age Social Expensive analyses, but low treatment costs for society Other Costs, disadvantages (qualitative description should be provided of all impacts, along with either quantification of the impacts or examples and underlying assumptions.) Financial Health environmental Social Other Alternative ways of achieving the same objective, and their pros and cons relative to the option chosen. mothersmilk exposure to dioxins, cadmium, mercury organochlorine compounds neurodevelopmental disorders bone density measurements for osteoporosis in connection with pesticides, organochlorine compounds, cadmium Is further analysis needed?: What would be the work programme?:

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Option 3.5 Preliminary statement : Most health outcomes of interest for the environmental health issues are the result of

combined exposure to several health determinants (physical pollutants, social conditions, lifestyle, genetic background…). The result can lead often to a marginal role of the environmental factors in the process of the incidence of the health outcome, even if the relation between the physical factor and the effect is clearly causal. Furthermore, sometime, other factors enhance the impact of the exposition to the environmental factor. Therefore environmental public health policies will be more efficient if they can these interactions and multi causalities into account. (working group: EH Indicators…….. Name: Philippe Pirard

Option for action: Develop methods to monitor and evaluate effects of combined exposure What is happening just now (describe the current situation qualitatively and quantitatively where possible)?: What is the problem (qualitatively and quantitatively where possible)?: There is a need for more integrated methods for health risk assessment which considers the full range of exposures

and health effects and can be applied early in the policy or planning process. This tool should also make explicit the trade-offs of certain policy options.

To assess the disease burden of environmental exposures one must consider at least three important dimensions of public health: loss of life expectancy, loss of quality of life, and number of people affected (social magnitude). In the Global Burden of Disease project Murray and Lopez applied disability-adjusted life years (DALYs). DALYs are the sum of years of life lost and years lived with disability that are standardised by means of severity weights.

How does this option contribute to the goals of the Strategy ? 1) to the European Integrated Environment & Health Monitoring and Response System :

– Generate synergies and facilitate the sharing of data and methodologies – Increase the understanding of the environment and health relationship – Improved data availability, accessibility, comparability – Enhanced exchange of information

2) to improve public health with respect to environmental risk factors 3) to the research agenda

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4) to raise awareness, to educate Increase the understanding of the environment and health relationship Main stakeholders affected by the option and how they are affected: Involves many sources of information and experts to synthesise this information.

The European commission and member states will need to furnish information on : Various sources of pollution, Social characteristics, Demography EURSOTAT, EEA, and DGSANCO will need to share and harmonise their data and indicators Researchers will need to enforce their research on exposure –response relationship and interaction between environmental and other factors

benefits, advantages (qualitative description should be provided of all impacts, along with either quantification of the impacts or examples and underlying assumptions. For example, how will the impacts relate back to the problem identified above?): Financial Assessment of multiple attributable risk can help to build cost –effective public health policies

On the other hand The estimation of disease burden attributed to risk factors or a common source has the potential that policy can directly act on risk factors. It will allow the evaluation of possible trade-offs among specific health targets pertaining to a specific policy e.g. air pollution vs. accidents.

Health Can help to assess the environmental priorities concerning health Can help to find the most effective targets for action Additional ecological benefits, over and above the health benefits can be added

environmental Helps to allow funding where it is the most cost -effective Social Can serve as a base for social discussions and prioritisation compared to other aspects (economic, politics ..) Other Costs, disadvantages (qualitative description should be provided of all impacts, along with either quantification of the impacts or examples and underlying assumptions.) Financial Needs insight in the causal web and that the results should be integrated into wider frameworks for preventive action.

In these types of integrated assessments many substantial uncertainties are accumulating. Health environmental Social Despite available methods to describe and quantify uncertainty, it may be difficult to convey the right message to

policy makers and the public. Other

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Alternative ways of achieving the same objective, and their pros and cons relative to the option chosen. Is further analysis needed?: Yes What would be the work programme?:

Example of integrated indicators: Disease burden The impact of environmental related exposures on human health can take numerous shapes of various severity and clinical significance. Effects of air pollution for example range from increase in respiratory symptoms and hospital admission to mortality, while noise pollution is associated with annoyance, sleep disturbance and (perhaps) increased hospitalisation rates for cardiovascular diseases. For traffic accidents, we consider injuries ranked with an Abbreviated Injury Scale going from fatal to light. These different health effects have to be compared with other health effects caused by competing decision alternatives (comparative risk assessment) or with costs of measures (costbenefit-analysis). Thus, a common metric for health outcomes that allows aggregating a wide range of health outcomes would enable decisions that are more informed (Hofstetter, 2002; Hollander et al, 1999). Experience with health metrics in environmental decision-support tools is limited to the use of years of lives lost, monetized estimates of health impacts and Quality Adjusted Life Years (QALYs) or Disability Adjusted Life Years (DALYs). All these studies used human health metrics in order to aggregate different health outcomes in one dimension so as to make them more comparable and interpretable (Hofstetter, 2002). To assess the disease burden of environmental exposures one must consider at least three important dimensions of public health: loss of life expectancy, loss of quality of life, and number of people affected (social magnitude). In the Global Burden of Disease project Murray and Lopez applied disability-adjusted life years (DALYs). DALYs are the sum of years of life lost and years lived with disability that are standardised by means of severity weights.

Discussion The estimation of disease burden attributed to risk factors has the potential that policy can directly act on risk factors. This means, however, that one needs insight in the causal web and that the results should be integrated into wider frameworks for preventive action. It will allow the evaluation of possible trade-offs among specific health targets pertaining to a specific policy eg air pollution vs accidents.

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The strength of evidence for environmental health problems is variable and often very low. For future disease burden calculations a “sufficient level of evidence” should be defined (Eg as outlined by IARC or EPA) and uncertainties specified. On the other hand, while scientific evidence for environmental epidemiology is still sparse, decision-makers should avoid considering only those determinants of health that are adequately quantified (Pruss et al, 2001). Currently, WHO-Geneva is further developing the evidence base for environment-related disease burden estimation, describing the methodology and models for different risk factors (www.who.xx).. In these types of integrated assessments many substantial uncertainties are accumulating. Also, in the exposure-based Burden of Disease Calculations the fact that different risk factors influence the same outcome (and may interact) is usually not accounted for. Despite available methods to describe and quantify uncertainty, it may be difficult to convey the right message to policy makers and the public. If we choose an aggregated health metric to evaluate the health impact of e.g. road transport, it may be worthwhile to accompany this with a semi-quantitative discussion to evaluate o.a. whether specific groups are affected. Of course total DALYs can be broken down to severity, age, income etc to evaluate whether specific groups need protective decisions.. We may also include in such an evaluation the results of ongoing monetizing studies (e.g. cost-benefit analyses of transport measures using WTP ) In conclusion, an aggregated health metric can be used although the collection of the necessary population data (life tables, maybe community-based preference values) may take some time.

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Reporting format for options for actions

Option 4 Preliminary statement : (working group:E&H indicators Name: Luciana Sinisi. sinisi@apat.it

Option for action: Develop and adopt a framework for E&H integrated assessment for environment and health policy purposes using ad

hoc indicators What is happening just now (describe the current situation qualitatively and quantitatively where possible)?: Currently there are several methodologies and definitions of integrated assessment, but there is not a uniform

methodology set to be used on ordinary basis for environment and health integrated assessment in targeted scenarios. 1) Community policy background

Although there is a general institutional agreement on considering the importance of break in the link between health and environment, there is still a lack of a shared operational framework and methodology for E&H integrated assessment to be used by health and environmental operators on ordinary basis, both for health prevention (risk assessment) and health promotion (impact assessment) in environmental policies. Integrated assessment is advocate by Community policies (since Amsterdam Treaty) and WHO and there are already experiences on specific issue (e.g. transport, climatic change, Kiev protocol). In some Countries outside EU (e.g. Canada) guide lines for E&H integrated assessment are already developed and adopted by authorities. The need of integrated impact assessment is also a major issue in the European Strategy, according to European Health Action Plan (2003-2008), calling for addressing all health determinants in no-health sector policies and to Commission Communication (COM/20012/276def)) as well, calling for a new impact assessment method of sectoral strategic proposal (regarding also not only strictly environmental or health issues) which covers both regulatory proposals as well as other proposals having an economic, social and environmental impact investing all major initiatives presented at the European Commission, either in the Annual Policy Strategy or later in the Work Programme of the Commission. The system will be fully operational in 2004/2005. To integrate health aspects in environmental assessments is also advocate by environmental policies; for example the Commission Communication on effectiveness ((CCOOMM//22000033//333344 ddee ff..)) oo ff tteenn yyeeaa rrss aapppp lliiccaa tt iioonn oo ff EEnnvviirroonnmmeennttaa ll IImmppaacc tt AAsssseessssmmeenntt iinn EEUU uunnddeerr lliinneess tthhaa tt hheeaa lltthh aassppeeccttss aarree qquuiittee nneegglleecctteedd iinn aasssseessssmmeennttss aanndd ccaa llllss ffoorr aann iimmpprroovveemmeenntt iinn tthhiiss sseennssee.. TThhee iimmpp lleemmeennttaa tt iioonn oo ff SS EEAA ((SS ttrraa tteeggiicc EEnnvviirroonnmmeennttaa ll AAsssseessssmmeennttss)) oo ff EEuurrooppeeaann DDiirreecc tt iivvee iinn EEUU MMSS ((ssttaarr tt iinngg ffrroomm JJuullyy 22000044 )) iimmpp lliieess aa llssoo pprroocceedduurreess aaddddrreessss iinngg ppootteenntt iiaa ll ee ffffeeccttss oonn hheeaa lltthh oo ff PPoo lliicc iieess ,, PPllaannss aanndd PPrrooggrraammmmeess aatt aannyy aaddmmiinniiss ttrraa tt iivvee lleevvee ll.. 2) Current situation in EU

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Although HIA can be integrated with other forms of impact assessment ( environmental impact assessment (EIA), strategic environmental assessment (SEA), economic impact assessment, social impact assessment) in the practice, besides spotted experiences, methodologies are generally used separately for environmental (specially EIA and SEA) and health assessments, though they share common procedures and can benefit of harmonised informative feedings: data, monitoring procedures, integrated/composite indicators. All approaches and applications have at their core the principle that an interdisciplinary, multi-sectoral approach to assessing the impacts of a development (project or policy) is best practice. They advocate an approach that assesses how a development affects the 'whole environment' including physical, economic, and social aspects - that is all health determinants -rather than focusing on its impact on a single dimension such as the physical environment. In the guide of DG SANCO ( Luxembourg, 17 December 2001 MH/ D(2001) Health Impact Assessment (HIA) is defined as a tool to address the potential impact of policies and actions on health and the production or prevention of diseases, disability or death. EEA defines Integrated assessment as an interdisciplinary process of structuring knowledge elements from various scientific disciplines in such a manner that all relevant aspects of a complex societal problem are considered in their mutual coherence for the benefit of decision-making. Although health protection is always underlined to be a key issue in any environmental assessment, in practice, little has been achieved in integrating health criteria and health professionals into the process, including externalities of health impact. The interest of public decision makers for the “economic” value of impacts, in order to perform an informed cost-benefit assessment of any policy, plan or programme, have produced several experiences in certain sector as climatic change or transport and, often, the cost of health impacts (mostly morbidity and mortality) are dominant even if many variables are still uncertain to evaluate. For example in the Commission funded European project, the ExterneE project a new methodology for quantifying energy-related environmental externalities of transport based on a bottom-up approach the Impact Pathway Approach . This approach was also used to estimate the health costs associated with air pollution due to tail pipe emissions from cars. It follows the complete chain of causal relationships, starting with the emission of a burden, through its diffusion and chemical conversion in the environment, to its impact on the various receptors (humans, crops etc.) and, finally, the monetary valuation of such impact.

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So, information is generated on three levels: 1) the increase in pressure burden (e.g. additional emissions and ambient concentration of SO2 in µg/m3) due to an additional activity (e. g. one additiona l trip on a specific route with a specific vehicle, train, ship, plane), 2) the associated impact (e.g. additional hospital admissions in cases) and 3) the monetary valuation of this impact The goal of the monetary valuation of damages is to account for all costs, market and non-market Economists have developed several tools for no-market costs e.g. approach methods based on Willingness to Pay (WTP) or Willingness to Accept (WTA) studies, which can be either direct (based on stated preference surveys and the concept of hypothetical markets) or indirect (based on revealed preferences and the concept of surrogate markets), e.g. WTP to avoid the additional hospital admissions, or the valuation of an asthma attack include not only the cost of the medical treatment but also the willingness to pay to avoid the suffering. As a monetary value for the risk of acute mortality, the ‘value of a statistical life’ (VSL) has extensively been used, mainly for accident costs. However, for monetising risks of chronic mortality, the ‘VLYL’ (value of a life year lost) approach was applied, as the use of the VSL might lead to inconsistencies The externalities assessment is not generally brought in the assessment process. If that will happen in the development of an integrated framework will allow a more consisted and informed assessment to support also the choice of policy among different options. This will also promote the use of information requirements, converted to ad hoc indicators, to facilitate the process of decision making. Data requirements indeed have very much in common with other E&H assessment needs. Uncertainty in externality estimates arises from a number of sources but, in general, the largest uncertainties are those associated with impact assessment and valuation, rather than quantification of emissions and other pressures, mostly depending on availability and quality of information, like e.g

- The variability inherent in any set of data; - Extrapolation of data from the laboratory to the field; - Extrapolation of exposure-response data from one geographical location to another; - Assumptions regarding threshold conditions; - Lack of detailed information with respect to human behaviour; - The need to assume some scenario of the future for any long term impacts;

What is the problem (qualitatively and quantitatively where possible)?: The ownership of the EIA, SEA or other impact assessment process by agencies that are not related to the health

sector has been shown to be an obstacle to the effective integration of health concerns. At the same time public health planning, for environmental health issues, is not often coordinated with environmental

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policies and environmental information and tools as well. Since activities are not done inside a common “institutionalised” procedure and framework since the beginning there is not a real exchange of knowledge (e.g. assessment tools ), experiences and shared priorities among environment and health operators. A “sharing context” will be also useful on harmonise information needs since definition of a shared framework integrated assessment can also improve the process of harmonising information feedings. On ordinary basis different information systems (health, environmental and statistical ) grow up separately, producing different monitoring procedures and data, not harmonised and non-comparable on several features , and tend to give support only for distinct aspect of health or environmental purposes, but not to consider them in a whole, since E&H issue represent , in the different systems themselves, only a “chapter” inserted in a major context (health policy and environment policy). This will lead to a (mis)use of resources on information (data, metadata and indicators) construction since environmental, health and statistical data are constructed in separate settings and systems, according to different laws or reporting obligations (sometimes overlapping), without integrating health/environment knowledge and tools in a common one for E&H purposes and without consistent information to policy maker on exposure to environmental risks or impacts (externalities included) for a cost-benefit analysis for the implementation of any policy, plan or programme, for setting surveillance, enforcement and research priorities. Any assessment procedure will need information (data or indicator) and to construct information inside an already “common context”, that is an operational framework, will save resources and improve skills for a better E&H management. E&H ad hoc indicator designed inside assessment scenarios can avoid data comparability, availability and accessibility problems, costly to adjust.

How does this option contribute to the goals of the Strategy ? 1) to the European Integrated Environment & Health Monitoring and Response System :

– Generate synergies and facilitate the sharing of data and methodologies – yes – Increase the understanding of the environment and health relationship – yes – Improved data availability, accessibility, comparability – yes – Enhanced exchange of information and operational tools – yes

2) to improve public health with respect to environmental risk factors - yes 3) to the research agenda – yes 4) to raise awareness, to educate – yes

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benefits, advantages Financial More informed support for a consistent cost/benefit analysis knowledge based of resource distribution (surveillance

and monitoring) and Strategy priorities (environmental health risk and impacts, mitigating actions, Monitoring and Response System)

Health allow preventive policy to be better targeted. environmental Improve health promotion in environmental policies Social Improve addressing environmental health and no-health determinants in assessments and raising awareness for

behavioural determinants Statistics Better targeted and prioritised surveys Costs, disadvantages (qualitative description should be provided of all impacts, along with either quantification of the impacts or examples and underlying assumptions.) Financial Cost for training, implementation and maintenance at EU and MS level Health Training programme environmental Training programme Alternative ways of achieving the same objective, and their pros and cons relative to the option chosen. Main alternative is to keep the existing systems separate and optimise monitoring systems for E&H purposes. This would be more informative in detail, maybe, but much more expensive without specific gain for understanding the problem in the whole and with the loss of trained personnel on E&H issue (long term investment).

What would be the work programme?: MANDATE • Commission act to assure the development and adoption of European E&H integrated assessment framework

that has to be implemented in MS Alternatives to the development of methodology framework: a) Mandate to research agenda b) Mandate to the new coming-up E&H steering committee inside the EHIS/Committee (with participation of

national representatives This will also allow a better development of ad hoc E&H indicators and knowledge flows on national and European level

• MS will endorse the process of harmonising information feedings for the set integrated assessment procedure and the development for ad hoc indicators

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Reporting format for options for actions

Option 4.2 Preliminary statement : Linkage between E&H indicators and geographical information system is a good way to

integrate environmental and health information and activities responsible of potential risks, particularly in environmental impact of cocktail environmental exposure and synergetic effects of even low concentration of individual pollutants or not yet identified pollutants (working group: E&H Indicators Name:Marie-Christine De Wolf……………………)

Option for action: Tools for awareness raising and improved communication to the public Tools for improved linkage of EH data with geographical information

What is happening just now (describe the current situation qualitatively and quantitatively where possible)?: - For the present time environmental and health impacts are analysed and estimated through vertical

toxicological analysis considering pollutants individually. - The Global Monitoring for Environment and Security (GMES) initiative of the commission will bring a

comprehensive understanding of environmental factors potentially having health effects. In order to generate synergies, facilitate the sharing of data and methodologies and increase the understanding of the environment and health relationship, some link should be established between health data with environmental and geographical data. This will allow to obtain a picture of the exposure of population to environmental pollution and the resulting adverse health effects (cf. INSPIRE initiative, which is a multi- thematic and multisectoral initiative). Therefore reliable data/indicators are necessary (cf. option “Harmonised methodology for analysis of routinely collected local data”)

- What is the problem (qualitatively and quantitatively where possible)?: - Pure vertical and toxicological analysis don’t take into account synergetic effects of exposure to cocktail of

pollutant or exacerbation processes to sequential exposure to different pollutants, etc… This therefore does not easily allow an assessment of the health impact of activities.

- The development of the GMES and INSPIRE processes are in their early stages and should be further developed. A link between environment, health and geographical data bases should definitely be further improved and standardised. Therefore a set of harmonised and standardised indicators and standardised methodologies are necessary. According to the option “Harmonised methodology for analysis of routinely

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collected local data”, we propose simultaneously to do pilot testing on an existing set of indicators (ex. WHO set of indicators). This pilot testing should develop guidelines to create the link between the different data bases (environmental, health and geographical).

How does this option contribute to the goals of the Strategy ? 1) to the European Integrated Environment & Health Monitoring and Response System :

– Generate synergies and facilitate the sharing of data and methodologies – Increase the understanding of the environment and health relationship – Improved data availability, accessibility, comparability – Enhanced exchange of information

2) to improve public health with respect to environmental risk factors 3) to the research agenda 4) to raise awareness, to educate Developing the link between environment, health and geographical data bases will allow to:

- generate synergies, - facilitate the sharing of data and methodologies, - improve and increase the understanding between environmental exposure and health effects, - develop tools for education, communication, training to a wide range of different targeted publics.

Main stakeholders affected by the option and how they are affected: * The European Commission should allocate means to:

- ensure the systematic and comprehensive collection of data of the proposed pilot testing project; - develop a European Integrated Environment and Health Monitoring and response system, - integrate the collected data (mentioned her above) in their European Integrated Environment and Health

Monitoring and response system; - extract the combined data and make some provisional interpretation; - ensure the validation of the interpretation of combined data by research institutions or experts groups/networks; - assess the process and provide guidelines for future regulation and implementation with the harmonised and

standardised set of indicators (see option “Harmonised methodology for analysis of routinely collected local data”);

- develop and deliver trainings among the different users of the integrated data bases at all levels; - encourage other regional or local pilot testing projects within the same framework (GMES and INSPIRE) with

potentially parallel epidemiological studies.

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Member States will ensure that: - the different users of the integrated data bases get the necessary training in order to facilitate the

implementation of the pilot testing project and the standardised protocols; - means are allocated to allow exchange of validated observations.

Member Sates will encourage local pilot testing projects cf. assessment of particular activities, integration of local statistical data bases, etc… within the framework proposed by the EU (GMES and INSPIRE) with potentially parallel epidemiological studies.

Research Institutions/Expert groups will need to : - validate the observations and interpretation made from the extraction of the combined data (reference could be

made to existing epidemiological studies); - exchange the results of their observations through scientific networks (universities or professional networks.

benefits, advantages (qualitative description should be provided of all impacts, along with either quantification of the impacts or examples and underlying assumptions. For example, how will the impacts relate back to the problem identified above?): Financial - A better understanding of the adverse affects of activities or combined situations will allow to develop more

targeted strategies and actions plans and gain effectiveness in the implementation phase and results.

Health - Increased understanding of the impact of activities or specific situations, particularly if combined data allow to highlight similar effects around similar activities or a gradient of effect around a particular local activities. This will improve the potential to develop more preventive oriented and targeted strategies and actions and therefore reduce the impact of the environment on the public health.

environmental - Increased understanding of the impact of activities or specific situations, particularly if combined data allow to

highlight similar environmental impacts around similar activities or a gradient of environmental impact around a particular local activities. This will improve the potential to develop more preventive oriented and targeted actions (sanitation programs, …) and therefore reduce the impact of the potentially damaging activities on the environment.

Social A better understanding of the impact of activities or environmental situations can be further used :

- for education and training programs,

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- awareness raising, - development of targeted risk communication, - development of public participation (cf. Aarhus Convention) to project development and decision-making

processes, - as a tool in decision making processes by the different stakeholders (promotor of a project, authorities giving

permits, neighbours, …), - arise a sample of good practises, which can be further disseminated through networking.

Other Costs, disadvantages (qualitative description should be provided of all impacts, along with either quantification of the impacts or examples and underlying assumptions.) Financial Estimation can be done through the pilot testing projects (in European (WHO set of indicators pilot testing), National,

Regional or local level). Health None disadvantages environmental None disadvantages Social None disadvantages Other Alternative ways of achieving the same objective, and their pros and cons relative to the option chosen. None Is further analysis needed?: Cf. role of Research institutions What would be the work programme?: See above.

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Option 5.1 Preliminary statement : For environmental health surveillance, it seems very important to define indicators not only to

describe a phenomenon, assess its burden, or facilitate research but also to guide public health action and survey its impact. Such a work consists in the implementation of indicators to survey the R part of the DPSIR model developed by the EEA (Driving force- Pressure – State- Impact –Response) which consists of an appropriate answer to the particularities of an environmental health problem. (working group: EH Indicators…….. Name:Philippe Pirard, Brigit Staatsen)

Option for action: Develop indicators for policy performance What is happening just now (describe the current situation qualitatively and quantitatively where possible)?: Too often the measurement of response indicators is forgotten in public health monitoring systems What is the problem (qualitatively and quantitatively where possible)?: - insufficient knowledge about the issues of a problem or risk perception before and after an information

campaign. (ex. : health risks due to exposure to radon) - insufficient knowledge about the level of compliance to action recommendations or regulations, or the exposure

to a pollutant before and after action number of state (for example % of houses with high levels of radon detected and/or remediated in an area)

- insufficient knowledge about the co-exposure to other risk factors. Taking into account other factors important to assess correctly the success of action is also important (for example surveys showed that the compliance to action concerning radon levels in houses is more important on population of old non smokers than at risk population (families with children, young smokers).

- insufficient use of indicators of health (final step) are also useful. Their relevance is obvious for short term effects (for example number of admissions to hospital for cardio-vascular diseases related to urban air pollution). It is also very important for long term and multifactorial effects (tendency of lung cancer linked to addiction to smoking, exposure to radon, and asbestos…)

- establish indicators at the European level allowing comparison between policies from each country and their progress are important

How does this option contribute to the goals of the Strategy ? 1) to the European Integrated Environment & Health Monitoring and Response System :

– Generate synergies and facilitate the sharing of data and methodologies – Increase the understanding of the environment and health relationship

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– Improved data availability, accessibility, comparability – Enhanced exchange of information

2) to improve public health with respect to environmental risk factors 3) to the research agenda 4) to raise awareness, to educate - Generates synergies and facilitates the sharing of data and methodologies

- Improves data availability, accessibility, comparability - Enhances exchange of information - Helps to improve public health with respect to environmental risk factors Can raise awareness

Main stakeholders affected by the option and how they are affected: Strong interaction between epidemiologists, environmental engineers, public health officers and deciders is necessary

to give the opportunity, as soon as a public health action plan is defined, to delineate indicators which targets are the assessment of the good progress of the action step by step up to the public health final result.

benefits, advantages (qualitative description should be provided of all impacts, along with either quantification of the impacts or examples and underlying assumptions. For example, how will the impacts relate back to the problem identified above?): Financial Allows quick redefinition of policies for a better efficiency Health environmental Helps to delineate real cost–effective policies Social Allows assessment of the efficiency of a policy from other partners than policymakers Other Costs, disadvantages (qualitative description should be provided of all impacts, along with either quantification of the impacts or examples and underlying assumptions.) Financial No Health No environmental No Social No Other Experts can quickly work on that topic for traffic road, radon , noise. Alternative ways of achieving the same objective, and their pros and cons relative to the option chosen. To do nothing in that goal and to launch apparently convenient actions without knowing their real efficiency Is further analysis needed?:

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What would be the work programme?: Systematic conception of indicators in order to assess the effectiveness of a new environment and health policy step

by step. Transport, ETS and radon can be candidate to test this process In the monitoring system, the environment and health factors must be measured and analysed : a. with respect of the time lags. Time series analysis can be convenient for short-term effects without too much confounder at this scale (ex : urban air pollution and specific mortality and admissions to hospital(because impacts are not instantaneous) b. at specified sites that are representative geographically representative of the problem(concerning exposure to a pollutant, or the population targeted) c. in relation to defined populations with period of exposure. d. with a quantitative understanding of the expected population attributable disease fraction

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Option 6.1 Preliminary statement : E&H indicators are a valuable tool to adapt the information to the different levels: public,

doctors, politicians, etc… (working group: E&H Indicatios Name:Marie-Chhrisitne de Wolf, Vesna Smaka Kincl……………………)

Option for action: Tools for awareness raising and improved communication to the public What is happening just now (describe the current situation qualitatively and quantitatively where possible)?: - The Aarhus convention (AC) was adopted through EU parliament and implementation is obligatory for MS.

The main objectives of ACs is free access to environmental data, public participation in decision-making and access to justice in environmental matters. It is very important to inform, educate and involve public and NGO in all environmental procedures to reach better results for protecting human health, environment and natural resources. Current situation: the communication, educating and involvement of public and NGO is still not enough efficient. It is even more obvious problem in new MS.

- reports at different levels (EEA, regional reports (ex. In Wallonia: “Tableau de bord de l’Environnement wallon”, WHO, … ),

- the knowledge seems to be clear in terms of occupational health for « the healthy worker profile » exposed generally to well known chemicals and to 1 or 2 chemicals at the same time.

What is the problem (qualitatively and quantitatively where possible)?: - The common strategy for implementation of AC should be upgraded with the connected environment and

health matters. Implementation of the strategy should be stressed mostly at the local level. Some local activity plans should be developed specially for new MS and some of them also implement as an example of good practise.

How does this option contribute to the goals of the Strategy ? 1) to the European Integrated Environment & Health Monitoring and Response System :

– Generate synergies and facilitate the sharing of data and methodologies – Increase the understanding of the environment and health relationship – Improved data availability, accessibility, comparibility – Enhanced exchange of information

2) to improve public health with respect to environmental risk factors 3) to the research agenda 4) to raise awareness, to educate - Reliable E&H indicators are necessary to increase the understanding between environment and health, included

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related criteria’s such as lifestyle, etc…Increased understanding will increase the knowledge (this also refers to identified research needs) and will allow the development of good quality training programs. Based on reliable training programs, the message can be adapted to other potential publics (politicians, public, families, etc…) through more “speaking” E&H indicators in order to raise their awareness, educate people and ensure more efficiency while implementing actions.

- Increasing communication and awareness raising will produce increasing background information which will be used by the public and NGO’s, local associations or experts to further assess ecological and health problems.

- Increasing communication and awareness raising will generate additional synergies and facilitate the sharing of data and results to increase understanding and co-operation between all stakeholders and also create a link between them (cf. development of strong networking).

- The use of reliable and understandable E&H indicators will allow to create the bridge between environmentalists, health actors and the public, develop some common language and gain trust from all parties … which can be more than useful in appearing crisis situations.

- Main stakeholders affected by the option and how they are affected: * The European Commission should ensure that identified experts in different environmental and health threats get

the time, opportunity and the means to: - analyse and interpret the available E&H indicators at the local level in order to sharpen their knowledge, - further develop the training programs and local and regional actions plans.

* The EC should also allow and encourage exchange of information (E&H indicators, related reports at different levels (from local to European), etc…) between experts, professional associations, NGO’s etc…, through professionals and NGO’s networks, in order to increase the global knowledge, sharpen the quality of the training programs and build better consensual messages addressed to professionals, politicians and the public. * The EC should develop European strategies or agendas (with specific focus in new MS) in order to encourage awareness raising, education and participation of public and NGO’s in decision making processes (cf. AC). * EU should develop communication processes between doctors, public health professionals and the public/patients about the potential/real environmental and health risks they are exposed to and educate environment and health professionals to risk and crisis communication.

Member States will ensure that, at their level, experts in different environmental and health threats get the time, opportunity and the means to:

- develop national and local strategies or agendas to create awareness raising, education and participation of public, local associations and NGO’s in decision making processes (cf. AC).

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- implement developed communication strategies (at the national and local level), - analyse and interpret local and regional available E&H indicators, - encourage exchange of good practices and exchange of information and results within international networks of

professional associations, - develop training programs based on validated and standards E&H indicators, - deliver training programs to environmental and health professionals (doctors, public health professionals,

etc…), - develop/organise brochures, Internet sites, conferences …based on validated and standard E&H indicators in

order to raise awareness. - develop communication processes between doctors, public health professionals and the public/patients about

the potential/real environmental and health risks they are exposed to. Research Institutions will need to:

- validate the interpretations made from the collected E&H indicators, further analyse the data, sharpen the knowledge and develop training for professionals;

- further develop and upgrade the data bases on environmental and health, - further evaluate and estimate health statistics data and connection with European, national, regional and local

state of environment, - develop communication strategy between different actors (scient ists, government, decision makers, citizens,

NGO’s, … ) on regular basis and in crisis emerging threats, - and develop the methods of communications addressed to public and NGO’s.

benefits, advantages (qualitative description should be provided of all impacts, along with either quantification of the impacts or examples and underlying assumptions. For example, how will the impacts relate back to the problem identified above?): Financial By developing validated knowledge through the use of validated and standards indicators, through comparisons

between equivalent threats, this will allow politicians to develop more efficient policies, programs and actions plans and therefore better externalities. Development and after the implementation of the strategy could help to use the existing resources more efficiently. Financial benefit will be more obvious in long term perspective but the success is assured because of education and information of public as a final target group. The public behaviour and reaction is the main motive power.

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Health Developing training programs, awareness raising brochures or conferences based on validated and standard E&H indicators will allow developing reliable material which will allow to improve the exiting knowledge by increasing potential comparison between equivalent environmental and health threats (ex. around same type of industries, activities, etc…). In general, better information at the European, national and local level on the environmental drivers of health issues, to allow preventive policy to be better targeted. More specifically, data will improve in the following ways: as a public education, information, participation and finally their behaviour as a important aim how to reach the final goal public health in general. Public …patients should be aware of the risks they are exposed to, including environmental and health potential risks.

environmental - Developing training programs, awareness raising brochures or conferences based on validated and standard E&H indicators will allow developing reliable material which will allow to improve the exiting knowledge by increasing potential comparison between equivalent environmental and health threats (ex. around same type of industries, activities, etc…). - Additional ecological benefits will be protecting the natural resources: drinking water, air, soil, etc...

Social - Developing training programs, awareness raising brochures or conferences based on validated and standard E&H indicators will allow to develop reliable and “trustable” material., which will ease the risk communication in case of emerging threats. - Different E&H indicators can be used to address the message to different targeted publics. - Networking, increased understanding, increased transparency and visibility between all stakeholders (public, NGO’s, national and local authorities, experts, local associations) in decision making processes. - The process stimulates upgrading of general public awareness and has an impact on their habits (cf. improvement of lifestyles).

Other Costs, disadvantages (qualitative description should be provided of all impacts, along with either quantification of the impacts or examples and underlying assumptions.) Financial These are cost for EU, national, regional and local levels. There are no cost estimations for each level yet, this depends

on each level’s environmental and health priority. It has to be divided into 2 phases and the different levels: firstly the development phase of the strategy at all levels (European, national, regional and local) and secondly implementation phase of the developed strategy at all levels.

Health No disadvantages environmental No disadvantages Social No disadvantages

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Other Alternative ways of achieving the same objective, and their pros and cons relative to the option chosen. Is further analysis needed?: Cf. role of research institutions What would be the work programme?: See above.

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Option 6.2.1 Preliminary statement : To be successful with the Environment and Health Strategy it is important to strengthen

teaching of environmental health/medicine in universities within member states. It would be good for European Commission to support development of unified training in relation to needs, by drawing on good practices in all countries and 'levelling up. (working group: EH Indicators…….. Name: Dirk Pallapies, Monica Nordberg)

Option for action: Promote Environmental Health /Environmental Medicine training & raise awareness for quality requirements at

involved parties/professionals What is happening just now (describe the current situation qualitatively and quantitatively where possible)?: Some but few countries have compulsory courses as part of the medical curricula Environmental Medicine and also in

master of public health- MPH program courses are offered. Training programs include lectures, seminar work and side-visits. The aims and contents are: Giving knowledge of principles in environmental health/medicine and influence of environmental factors on human health including ongoing activities in the field both on national and international level, aspects of changes in the ecological system influence on and importance for human health in order to provide understanding and methods for risk assessment including understanding law cases and aspects of law.

What is the problem (qualitatively and quantitatively where possible)?: How does this option contribute to the goals of the Strategy ? 1) to the European Integrated Environment & Health Monitoring and Response System :

– Generate synergies and facilitate the sharing of data and methodologies – Increase the understanding of the environment and health relationship – Improved data availability, accessibility, comparability – Enhanced exchange of information

2) to improve public health with respect to environmental risk factors 3) to the research agenda 4) to raise awareness, to educate

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Increase the understanding of the environment and health relationship Main stakeholders affected by the option and how they are affected: EU, WHO, National Organisations, all levels of educational programs benefits, advantages (qualitative description should be provided of all impacts, along with either quantification of the impacts or examples and underlying assumptions. For example, how will the impacts relate back to the problem identified above?): Financial More and better preventive measures established with increased knowledge about relationship between environment

and health Health Increased awareness in individuals at various levels how to act for a healthy environment, e.g. preventing the pollution

of the environment by noise, irradiation, or toxic substances environmental Shared interest creates an increased awareness of health and environmental issues Social could be performed at moderate cost level Other Costs, disadvantages (qualitative description should be provided of all impacts, along with either quantification of the impacts or examples and underlying assumptions.) Financial Moderate costs Health environmental Social Other Alternative ways of achieving the same objective, and their pros and cons relative to the option chosen.

• strengthen environmental health/medicine in the medical curricula (university, other health professions) • strengthen interdisciplinary training programmes • develop training programmes for teachers in day care centres and schools • highlight good research programmes for know how transfer

Is further analysis needed?: Cf. role of research institutions What would be the work programme?: Medicine training & rise awareness courses in environmental health/medicine for health work with people

representing different disciplines within public health work. ( e.g. physicians, environmental health officers, nurses, public health workers) They should give knowledge in understanding how factors in the environment influence human

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health and how to regulate environment in order to protect from development of illness. By mixing health work people representing different disciplines within public health work would promote an understanding of between specialists and to promote teamwork.

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Option 6.2.2 Preliminary statement :

(working group: EH Indicators.. Name: Dirk Pallapies, Monica Nordberg) Option for action: Promote harmonisation of environmental health/medicine and its organisation and structure throughout Europe What is happening just now (describe the current situation qualitatively and quantitatively where possible)?: Within EU member countries differences exist to what extent Environmental Health/Medicine exists as subject in

various curricula. Presently this is exemplified that for In southern European countries specialists within in this field are often still seen as 'hygienists', and in eastern European countries are part of the former 'sanitary-epidemiological' service. This reflects the development of hygiene mostly dealing with sanitary issues including bacteriology and virology to the present form of environmental medicine/health focusing on influence of environmental factors mostly from chemical and physical factors. Many countries like Sweden define environmental medicine as a triangle with toxicology, epidemiology and risk assessment as the three cornerstones of environmental medicine.

What is the problem (qualitatively and quantitatively where possible)?: To be successful with the Environment and Health Strategy it is important to strengthen teaching of environmental

health/medicine in universities within member states. It would be good for European Commission to support development of unified training in relation to needs, by drawing on good practices in all countries and 'levelling up.

How does this option contribute to the goals of the Strategy ? 1) to the European Integrated Environment & Health Monitoring and Response System :

– Generate synergies and facilitate the sharing of data and methodologies – Increase the understanding of the environment and health relationship – Improved data availability, accessibility, comparability – Enhanced exchange of information

2) to improve public health with respect to environmental risk factors 3) to the research agenda 4) to raise awareness, to educate - Increase the understanding of the environment and health relationship

- contribute to a better networking and exchange of experts and their knowledge between the various EU member states

- facilitate not only the communication and collaboration between the various countries but also with the respective European bodies/organisations.

Main stakeholders affected by the option and how they are affected:

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EU, WHO, National Organisations, all levels of educational programmes benefits, advantages (qualitative description should be provided of all impacts, along with either quantification of the impacts or examples and underlying assumptions. For example, how will the impacts relate back to the problem identified above?): Financial Easier to establish more and better preventive measures when harmonised nomenclatures and procedures and

protocols are used throughout Europe Health Makes it easier and faster to implement knowledge and protective measures on a European level environmental Better and facilitated communication, and collaboration between national organisations and their European

counterparts Facilitation of exchange of humans resources

Social could be performed at moderate cost level Other Costs, disadvantages (qualitative description should be provided of all impacts, along with either quantification of the impacts or examples and underlying assumptions.) Financial Health environmental Social Other Alternative ways of achieving the same objective, and their pros and cons relative to the option chosen.

• harmonised definition of Environmental Medicine throughout Europe • develop harmonised degrees in Environmental Medicine • harmonised organisation and structure on governmental and regional level, e.g. one ministry taking the key responsibility for environmental

health/medicine issues Is further analysis needed?: What would be the work programme?: