Trends in Health in Europe and CA

8/4/2019 Trends in Health in Europe and CA

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Europe Zone Office, Budapest

TRENDS IN HEALTH

IN EUROPE AND

CENTRAL ASIA

Discussion paper

Prepared by Sonja Tanevska, Zlatko Kovac and Sophia Keri


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CONTENTS

Introduction page 3

Life expectancy and ageing page 4

Disease trends page 5

Communicable diseases page 6

Non-communicable diseases page 7

Health equity page 11

MDG page 11

Financing of health and social services page 12

Water and sanitation page 13

Equitable access to water and sanitation page 14

Atmosphere and climate page 15

Human health page 16

Urban health page 17


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HEALTH AND SOCIAL SERVICES

TRENDS IN EUROPE AND CENTRAL ASIA

FOR INTENRAL USE ONLY

Introdution

Europe Zone is one of the most developed amongst the IFRC zones. The most of the regionis covered by solid transport, communications and public amenities - such as water,electricity, housing and other services infrastructure. Still, a lot of challenges persist, andimproved health and social equity are important for the 21st century also.

This trend paper, presented by the Health and Social Care Team of the Europe Zone Officeof the IFRC, consists of two parts. In the first part, the paper analyses the main trends likelyto emerge or continue in the overall health situation of people living in the European regionup to 2015. The spread of some communicable diseases in this period is projected to fallback, nevertheless the still high numbers require attention from both the National Societiesand Governments affected. At the same time, due to improving access to health services andtreatments, non-communicable diseases, mainly caused by unhealthy life conditions or lifestyles, will gain share amongst the main causes of casualties.

The second part of the paper is based on analysis carried out by the WHO, concentrating onhealth equity, financing of health and social services, water and sanitation, atmosphere andclimate and urban health. The last tendencies and changes in these areas within theEuropean region are enumerated, and the projected impacts of these on health of the

European citizens are also analysed by the Health and Social Care Team.


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Life expectancy and ageing

During the 1990s, the average life expectancy of the 870 million people in the Europeanregion actually declined for the first time since World War II, largely owing to the deteriorationin health status in the NISs1 and some countries in Central and Eastern Europe.

Source: UNDP, 2009

The figures above present the reality of Eastern Europe, while in the Western parts lifeexpectancy is actually increasing and is prolonged. In the EU people live longer lives inbetter health. Some facts on the demographic situation of the region:

By 2030 there will be 34.7 million people over 80 in the EU, in comparison withtodays figure of18.8 million, this shows a rise of 84%;

Some countries in Central Asia belong to young countries proportion of people over60 is low, but trends are changing;

1 Newly Independent States


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Fertility and birth rates are decreasing (1.5 children/woman in the EU), therefore it isexpected that in 2030 there will be 18 million less children and young people thantoday;

Work force is ageing, number of working people (14 -65) is decreasing rapidly.

Today, people aged 65+ are one of the most vulnerable groups exposed to poverty andsocial exclusion. According to the Eurostat statistics for 2008, 19% of people aged 65+ wereat risk of poverty in the EU27 countries. Across Europe, older women face higher povertyrates than older men, for example in Belgium, 22% of women above the age of 65 are at riskof poverty. These numbers are even higher in some of the Member States: in Ireland onethird and in Cyprus more than half of women over the age of 65 are at risk of poverty.

The link between disease and age is also crucial from an economic and public policy point ofview. In the European countries, the proportion of those aged 65 and older is projected togrow from 15% in 2000 to 23.5% by 2030, whereas the proportion of those aged 80 and overis expected to more than double, increasing from 3% in 2000 to 6.4% in 2030. This trend isclearly one of the most important causes of the growing burden of chronic conditions and

diseases.

Disease trends

In almost all countries of the region, there has been an increase in the health gap betweenthe more and the less advantaged socioeconomic groups. Although the situation varies fromcountry to country, non-communicable and communicable diseases, accidents, mental healthproblems and complications related to pregnancy and child birth seem to be the major healthproblems in the region.

According to the Murray-Lopez baseline global scenario, a study completed by Prof.

Christopher J. L. Murray and Alan D. Lopez PhD in 1996 for the WHO, during the next 20years the number of deaths caused by communicable diseases will fall (from 34% to 15%globally), and cases of death and disability caused by non-communicable diseases willincrease in number. IFRC EZ team, analysed the Murray-Lopez baseline scenario for Europeand Central Asia region, and analysis is presented on the pages bellow.

The overall burden of disease is assessed using the disability-adjusted life years (DALYs)2as indicator.

2DALYa time-based measure that combines years of life lost due to premature mortality and years of life lostdue to time lived in states of less than full health.


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Source: WHO, Health Statistics and health information system, Projections of mortality and burden of disease,2004-2030

3

When analysing the above graph it is very visible that trends predicted until 2015 can bealigned into the following four groups:

1. Trends showing veryhighvalues ischemic heart disease and injuries;2. Trends showing moderatelyhighvalues unipolar depressive disorders, alcohol

disorders, HIV/AIDS and Alzheimer and other dementia;3. Trends showing moderately low values drug use disorders, lower respiratory

infections and tuberculosis);4. Trends showing lowvalues melanoma and other skin cancers.

The spread of communicable diseases in the region will be focused among keypopulations. For example, In Eastern part of the region, access to health services andtherapy will remain limited, HIV will continue spreading, and will appear as a life threateningdisease of PLWH. However, due to the increasing access to health services in WesternEurope, HIV is already now considered as a chronic disease. Key population at risk inWestern Europe are neglecting preventive measures, contributing to increase of spreadingHIV in this part of the region.

Tuberculosis will affect mainly people with lower social status, making up to 7% of totaldeaths and 6% of total DALYs from TB in the world (see figures 3.a. and 3.b.). However, in2015, throughout Europe, a significant number of the deaths caused by tuberculosis is

projected. This means, that the issue of TB infections can not be neglected, since TB wouldbe the cause for more deaths than f.e. drug abuse. Europe is keeping the 4 th place whencompared with other regions in the World.

3Here and further accessed from:http://www.who.int/healthinfo/global_burden_disease/projections/en/

0

2000

4000

6000

8000

10000

12000

14000

16000

3,901

1,736

8,331

4,349

14,90714,283

1,475

272

3,584

1,163

Fig. 2. Projected trends by DALYs by cause, numbers in (000s), 10 majordiseases in Europe, 2015 baseline scenario

HIV/AIDS

Lower respiratory infections

Unipolar depressive disorders

Alcohol use disorders

Ischaemic heart disease

Injuries

Tuberculosis

Melanoma and other skin cancers

Alzheimer and other dementia

Drug use disorders
http://www.who.int/healthinfo/global_burden_disease/projections/en/http://www.who.int/healthinfo/global_burden_disease/projections/en/http://www.who.int/healthinfo/global_burden_disease/projections/en/http://www.who.int/healthinfo/global_burden_disease/projections/en/


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Source: WHO, Health statistics and health information system, Projections of mortality and burden of disease,2004-2030

Source: WHO, Health statistics and health information system, Projections of mortality and burden of disease,

2004-2030

Analysing Europe as part of the global picture and comparing Europe to other regions in theworld, non-communicable diseases appear to have significant influence on the health ofEuropean citizens in the next decade.

10,24644%

503

2%

2,733

12%

1,475

6%

6,189

27%

1,938

9%

Fig. 3a. DALYs caused by Tuberculosis by region, numbers in (000s) and %,2015 baseline scenario

Africa

the Americas

Eastern Mediterranean

Europe

South-East Asia

Western Pacific

World alltogether: 23,084

389

39%

27

3%

116

12%

66

7%

26727%

125

12%

Fig. 3b. Number of deaths caused by Tuberculosis by region, numbers in(000s) and %, 2015 baseline scenario

Africa

Americas


Europe

South -East Asia

Western Pacific

World alltogether: 989


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DALYs caused by unipolar depressive disorders put Europe in the third place whencompared with other regions. Statistically it is in the middle of the graph, however thenumbers in trends are still high and require attention.

Source: WHO, Health statistics and health information system, Projections of mortality and burden of disease,2004-2030

DALYs caused by alcohol abuse put Europe in the third place when compared with otherregions. Alcohol abuse causes chronic illnesses, such as alcohol dependence, vasculardiseases (such as hypertension), cirrhosis and various cancers. Of the global loss of DALYs,4.7% can be explained by alcohol-related diseases.

Source: WHO, Health statistics and Health information system, Projections of mortality and burden of disease,2004-2030

However, from all deaths caused by alcohol use disorders in the world, 25% are predicted tohappen in the European region, placing the region the second place in the world.

6,236

8% 12,054

16%

6,699

9%

8,331

11%

25,077

34%

16,381

22% Africa

the Americas


Europe

South-East Asia

Western Pacific


Fig. 4. DALYs caused by Unipolar depressive disorders by region, numbers in (000s)

and %, 2015 baseline scenario

1,050

4% 5,351

22%

333

1%4,349

18%4,906

20%

8,686

35%


Africa

the Americas


Europe

South-East Asia

Western Pacific

Fig. 5. DALYs caused by Alcohol use disorders by region, numbers in (000s) and %,2015 baseline scenario


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When compared with other regions, Europe is ranked second in relation with DALYs due to

heart disease.


In the next decade, ischemic heart disease will be the main cause of death for Europeancitizens.


4

5% 25

28%

3

3%

22

25%

1921%

16

18%

World alltogether: 90

Africa

Americas


Europe

South -East Asia

Western Pacific

Fig. 6. Number of deaths from Alcohol use disorders by region, numbers in (000s)and %, 2015 baseline scenario

4,312

6%7,336

11%

7,342

11%14,907

22%

24,472

37%

8, 338

13%


Africa

the Americas


Europe

South-East Asia

Western Pacific

Figure 7: DALYs from Ischaemic heart disease by region, numbers in (000s) and %,2015 baseline scenario

0

500

1000

1500

2000

2500

13666

2122 22

2,374

638

31 16711

HIV/AIDSTuberculosis

Lower respiratory infections

Unipolar depressive disorders

Alcohol use disorders

Ischaemic heart disease

Injuries

Melanoma and other skin cancers

Alzheimer and other demenita

Drug use disorders

Fig. 8. Projected trends of number of deaths by cause, numbers in (000s), 10major diseases in Europe, 2015 baseline scenario


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Among the first 10 risks in European region, injures are also taking a significant place.


419

5%1,069

13%

709

9%

2,374

29%

2,369

29%

1,161

15%


Africa

Americas


Europe

South -East Asia

Western Pacific

Fig. 9. Number of deaths caused by Ischemic heart disease by region,numbers in (000s) and %, 2015 baseline scenario

37,164

20%

20,748

11%

23,613

13%14,283

8%

60,461

33%

28,568

15%


Africa

the Americas


Europe

South-East Asia

Western Pacific

Fig. 10. DALYs caused by Injuries by region, numbers in (000s) and %, 2015


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Health equity

Persistent problems of poverty and unemployment are exacerbating inequities and in manycountries are giving rise to deteriorating lifestyles, increasing violence and weakened socialcohesion. Doubts about the quality of health and other services and an imbalance betweenthe demand for and the availability of resources, have alarmed many countries that hard-wonsocial safety nets and benefits may be dismantled.

The social conditions, in which people live, exceedingly influence their chances to be healthy.Indeed factors such as poverty, social exclusion and discrimination, poor housing, unhealthyearly childhood conditions and low occupational status, are important determinants of mostdiseases, deaths and health inequalities between and within countries.

Even in the high- and middle-income countries of the European region the possibilities forsurviving and living a healthy life are still closely related to the socioeconomic background ofindividuals and families. These possibilities are reflected in substantial and even increasingsocial inequities in health within countries across Europe. For EU, reducing healthinequalities is a central part of a society based as much on the social justice as on economicsuccess. The importance of improving health in general and improving it among low-incomegroups is a matter of even greater urgency in the countries of central and Eastern Europeand within CIS4. The typical trend in health status, for the population as a whole, in most but not all of these countries is one of stagnation or decline, accompanied by increasingsocial inequities in health.

Two key ethical values in WHO Health 21 Strategy are equity in health and solidarity inaction. Equity in health is also stated as core value in 34 out of the 40 national healthstrategies, in WHO European region. Equity in health implies that, ideally, everyone couldattain their full health potential and that no one should be disadvantaged from achieving thepotential because of their social position or other socially determined factors.

Millennium Development Goals MDGsOne challenge for reaching the health and education MDGs relates to equity: uneven accessto resources and the exclusion of marginalized groups mean that the benefits associatedwith progression toward the MDGs are not widely shared by all.5 These inequalities areclosely related to quality concerns, because the costs of low-quality education and healthcare are likely to be disproportionately borne by the poor.

Outdoor air pollution increasingly places both children and adults at risk, a problemparticularly acute in urban areas of fast-growing economies

Inequalities in access to health and educational services exist almost everywhere in the

world: the poor tend to be less healthy and less educated than the rich. But income is not theonly factor leading to unequal access. So too are differences in ethnicity, gender and socialstatus. In addition, the quality of education and health services is often unequally distributed.Nonetheless, poverty remains the largest roadblock to good health and education and canlead to a vicious cycle of deteriorating health, low demand for education, and increasedpoverty.

The interrelationships among environmental factors, child health, nutrition status, andeducation are strong and multifaceted, and together significantly influence progress toward

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the MDGs.6 Environmental risk factors such as access to water and sanitation play a role inmany diseases. It has been estimated that 23% of all deaths are principally attributable toenvironmental factors. Children are among those most vulnerable and adversely affected.Diarrhoea, malaria and lower respiratory infections are most closely linked to environmentalfactors.

Malnutrition is among the most important determinants of child mortality, together withrespiratory infection (largely caused by indoor air pollution), diarrheal diseases (mostly frominadequate water supply, sanitation and hygiene).

Financing of health and social services

Financial resources are often limited: among the countries of the OECD, for example, publichealth typically accounts for approximately only 9% of gross domestic product (GDP). This isstill a comparatively high percentage when compared to non-OECD countries. In theRepublic of Moldova, for example, public sector funding for health decreased by two thirdsbetween 1993 and 2003, when it stood at 3.4% of GDP. The trends are that financing of thehealth sector will increase, but demands for health services will increase as well.

With the aging of the population, portion of expenditures on social programs for older peoplewill further increase.

Globally, at the beginning of the 21st century, aid for health has scaled up dramatically tonearly $17 billion in 2006 (from $6.8 billion in 2000), with support from over 100 traditionaland non-traditional entities. Sources include new bilateral programs such as the USPEPFAR, private sources such as the Gates Foundation, and global funds such as GFATMand GAVI.7

6

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Aid fragmentation more donors with smaller shares of total aid is an emerging issue.

OECD DAC data for 61 poor countries and fragile states show that over 60% of countriesreceived aid from 20 or more different donors and over 75% of countries had 10 or moredonors together accounting for 10% or less of aid. This makes strong country-led strategiesmore important than ever.

Water and Sanitation

Universal access to safe drinking-water and adequate sanitation remains unrealized in manycountries in the European region. Infant mortality and morbidity from water-related diseasesare on the decline but significant sub-regional inequality remains. This jeopardizes not onlythe MDG related to environmental sustainability, but also those related to universal primary

education, poverty alleviation and maternal and child health. The region is generally on itsway to reaching the drinking-water target, although efforts remain vital to ensure access tosafe water in the home or dwelling, particularly in rural areas. The sanitation target, however,may well be out of reach for a significant number of countries.

Effects of gradual climate change and extreme weather events such as floods and droughtsform an additional challenge to the sustainable provision of safe water and adequatesanitation, and to the sustainable functioning of health systems in the region. In 2006, nearly140 million people (16%) in the Eastern Europe, Caucasus and Central Asia (EECCA) regionstill did not have a household connection to a drinking-water supply, over 41 million people(5%) did not have access to a safe drinking-water supply and 85 million people (10%) did nothave improved sanitation.

These general statistics do not reflect important changes in access to safe water andadequate sanitation that have occurred in the European region at the national level. Basedon a 2008 review, the WHO-UNICEF Joint Monitoring Programme (JMP) has observed someimpressive changes in access to improved sources water and sanitation (UNICEF and WHO,2008). While the percentage of the population that gained water supply coverage in theperiod 19902006, compared to the 1998 median population, was relatively modest in theWestern part of the region (typically 110%), it was very significant in the eastern part of theregion (20% in Azerbaijan).

The gains made over the same period with regard to sanitation were, however, more modest,and typically remained below 10% in the countries that participated in the review.
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At present, however, unacceptable levels of, in particular, childhood mortality and significantlevels of morbidity from water-related diseases caused by microbial pathogens, chemicalcontaminants and impaired hygienic conditions persist in many countries. Well knowndiseases such as hepatitis A, typhoid fever and bacillary dysentery remain a serious healthproblem for many countries in the region.

Equitable access to water and sanitationAccess to water and sanitation is often seen as a purely technical problem, while both socialand governance aspects are neglected. The criteria for the full enjoyment of the right towater, according to the WHO, are: sufficiency in quantity, safety to human health andorganoleptic acceptability, physical accessibility and economic affordability.

The affordability of water has a significant influence on the use of water and selection ofwater sources. Households with the lowest level of access to a safe water supply frequentlypay more for their water than do households connected to a piped water system. The highcost of water may force households to use alternative sources of water of poorer quality thatrepresent a greater risk to health. Furthermore, high costs of water may reduce the volume of

water used by households, which in turn may influence hygiene practices and increase risksof disease transmission. By way of illustration of the importance of this problem even forEuropean Union countries, it has been reported that in 2008 424,742 consumers in Belgium(approximately 12.13% of population) were in arrears with the payment of their water bills.8

Public understanding of the link between environment, drinking-water and sanitation, andhuman health is low in general. This is particularly problematic in the event of clearcontamination of drinking water, in relation to communication with health care providers,vulnerable populations and consumers at large. In the EECCA region, there is a relativelystrong focus on the quantitative, rather than the qualitative, aspects of water resourcemanagement. The water and health link is often seen narrowly as securing the necessaryamount of water for drinking and hygiene purposes. However, the increasing impacts of

climate change are changing perceptions. The relationships between environment, water andhealth are progressively becoming more prominent and appreciated. Nevertheless, waterand health issues do not figure prominently on many governments agendas, despite theirhigh social and economic importance.

Special attention is being given to the protection of vulnerable groups, including the growingpopulation of immune-compromised patients, the elderly and the very young.

According to the WHO, there is a clear difference between the geographical areas in theburdens of mortality and morbidity attributable to water resource division (WRD) outbreakswithin the pan-European region. This factor is directly linked to the access to improved watersupply at home in urban and rural areas. For instance, in WHO division of Europe countries

on EUR-B9

and EUR-C10

between 10% and 25% of the population in rural areas, and about80% in urban areas, suffer from poor water supply, in comparison to EUR-A11 countrieswhere 100% of the population in both rural and urban areas enjoy access to water.

According to the Federal Hygiene and Epidemiology Centre of Russian Federation, between2002 and 2008, 41.2% of surface sources of drinking-water and 17.3% of underground

8Anon, 2009

9 EUR-B: Albania, Armenia, Azerbaijan, Bosnia and Herzegovina, Bulgaria, Georgia, Kyrgyzstan, Montenegro, Poland, Romania,

Serbia, Slovakia, Tajikistan, the former Yugoslav Republic of Macedonia, Turkey, Turkmenistan, Uzbekistan.10EUR-C: Belarus, Estonia, Hungary, Kazakhstan, Latvia, Lithuania, the Republic of Moldova, the Russian Federation, Ukraine.11

EUR-A: Andorra, Austria, Belgium, Croatia, the Czech Republic, Denmark, Finland, France, Germany, Greece, Iceland, Ireland,Israel, Italy, Luxembourg, Malta, Monaco, the Netherlands, Norway, Portugal, San Marino, Slovenia, Spain, Sweden, Switzerland, theUK.
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sources in the Russian Federation did not comply with national standards of drinking waterquality.

Table 1. Percentage of drinking-water sources non-compliant with national sanitary standards, 20022008, minimummaximum (mean) and estimated number of people who drink water that does notmeet chemical or biological standards

Source: Federal Hygiene and Epidemiology Centre, 2009

An additional factor for the unequal spread of WRDs is the percentage of the populationconnected to sanitation facilities. In EUR-B and EUR-C countries, the figure is 1015% inrural areas and 7584% in urban areas, in comparison to EUR-A countries, where 95% ofthe population in rural areas and 100% in urban areas have access to sanitation.

In addition, in both EUR-B and EUR-C countries, only a low percentage of waste water istreated in an adequate and safe manner, which is threatening the environment, especiallythe quality of water bodies used for drinking-water or recreational purposes.

Facts and figures

Better management of water and sanitation in the WHO European Region wouldprevent disease over 30 million cases of water-related disease per year.

Worldwide, WHO estimates that around 6% of the global burden of disease is relatedto water. Infectious diarrhoea is the largest component and accounts for 1.7 milliondeaths per year: about 70% of the total.

Water, sanitation and health intervention typically reduces diarrhoeal diseases by 1530%, and significantly reduces other diseases.

The highest incidence rate of infectious diseases caused by poor drinking-waterquality is often found in children aged 611 months, a vulnerable time in life. In thisperiod, water and weaning foods are introduced in the diet, levels of maternalantibodies begin to decline, and the childs immune system is developing; crawlingdevelops and foreign objects are introduced in the mouth.

Estimates of the burden of diarrhoeal disease attributable to water, sanitation andhygiene in the European Region for children 014 years of age amount to over

13,000 deaths (5.3% of all deaths in the 014 age group), mostly coming fromcountries of eastern and South-Eastern Europe and Central Asia.

Providing the entire child population of Eastern and South-Eastern Europe andCentral Asia with access to regulated water supply and full sanitation coverage withpartial treatment for sewage would save about 3,700 lives every year.

Atmosphere and climate

Projections suggest further increase temperatures in Europebetween 1.05.5C by the endof the century, which is in average also higher than projected global warming (1.84.0C).Whether the EU's goal of less than 2C increase (compared to pre-industrial levels) will beexceeded depends on the effectiveness of the international climate policy regarding globalgreenhouse gas emission reductions. More frequent and more intense hot extremesand a
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decreasing number of cold extremeshave occurred during the past 50 years and this trend isprojected to continue.

Changes in precipitation show more spatially variable trends across Europe. Annualprecipitation changes are already exacerbating differences between a wet northern part (anincrease of 10 to 40 % during the 20 th century) and a dry southern part (a decrease of up to

20% in some parts of Southern Europe). The intensity of precipitation extremes such asheavy rain events has increased in the past 50 years, and these events are projected tobecome more frequent. Dry periods are projected to increase in length and frequency,especially in Southern Europe.

No clear trend in the frequency and intensity of storms has yet been observed, but thestrength of the heaviest storms is projected to increase, albeit with slightly lower frequency.Uncertainties for projected annual precipitation and frequency and the intensity of extremeevents continue to be larger than those for annual temperature. Climate variability andchange have contributed to an increase in ozone concentrations in Central and South-Western Europe, which is projected to continue. This may result in current ozone abatementpolicies becoming less effective.

Climate change, including changes in temperature, precipitation, glaciers and snow cover, isintensifying the hydrological cycle. However, other factors such as land-use changes, watermanagement practices and extensive water withdrawals have considerably changed thenatural flows of water, making it difficult to detect climate change-induced trends inhydrological variables. In general, annual river flowshave been observed to increase in theNorth and decrease in the South, a difference projected to exacerbate. Strong changes inseasonality are projected, with lower flows in summer and higher flows in winter. As aconsequence, droughts and water stress will increase, particularly in the South and insummer.

Human healthIncreased temperatures can have various effects on human health. The large number ofadditional deaths during the 2003 heat wave(more than 70,000, excess deaths reported in12 European countries) highlighted the need for adaptation actions, such as heat healthaction plans. Such heat waves are projected to become much more common later in thecentury as the climate continues to change, with mortality risk increases by between 0.2 and5.5% for every 1C increase in temperature above a location specific threshold. The hotsummer of 2003 in Europe is estimated to have led to EUR 10 billion of economic losses tofarming, livestock and forestry from the combined effects of drought, heat stress and fire.There is some evidence that winter mortality in Europe has decreased, but this could haveother causes, particularly improved housing and the prevention of winter infections.

Premature deaths, diseases and forced displacement of communities are some of the mostthreatening consequences. Because of this, there is growing recognition of the link betweenextreme weather events and health. In the long run however, the greatest health impactsmay come not from acute shocks such as natural disasters or epidemics, but from thegradual build-up of pressure on the natural, economic and social systems that sustain health,and are already under stress in many countries in the European region.

A number of the vector borne diseases and their appearances will change. The tigermosquito, a transmitter of a number of viruses, has extended its range in Europesubstantially over the past 15 years and is projected to extend even further.

Ticks and the associated Lyme disease and tick-borne encephalitis are moving into higheraltitudes and latitudes. There is a risk of additional outbreaks of Chikungunya (a virus that is
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highly infective and disabling but not transmissible between people) and a potential forlocalised dengue to re-appear.

Changes in the geographic distribution of the sand fly vector are occurring in severalEuropean countries and there is a risk of human Leishmania cases further north.

The main impacts of climate change in relation to water and health in the European regionare, inter alia:

Changing precipitation patterns, with increased water scarcity in the Southern areasand increased water availability in the Northern latitudes;

Change in precipitation extremes in both intensity and frequency, with higher floodrisks and associated mortality, physical injuries, infectious disease and psychologicaltrauma;

Reduced water availability, resulting in higher concentration of pollutants, and higherwater temperatures, resulting in more intense growth of micro-organisms, includingpathogens;

Projected further rises in lake and river surface water temperatures with increasing airtemperatures, which will have several effects on water quality and hence on humanuse of aquatic ecosystems.

Secondary effects include: Changes in water quantity and quality resulting from climate change that are

expected to affect food production and availability; this is likely to increase thevulnerability of marginalized groups, such as the poor, women, children and theelderly;

Impacts of climate change on the functioning and operation of existing waterinfrastructures;

Water resource management impacts on many other policy areas, e.g. energy,health, food security and ecosystem functioning.

Generally, to reduce the consequences in an effective way, adaption to climate changeneeds to be integrated into national and local health strategies and plans; and preferably tobe included into other sectors of national and regional policies. The principle of target settingmeans that coordination mechanisms must be established and a baseline analysis carriedout for each specific topic before specific targets are set.

Urban health

Two thirds of the population of the European region live in towns and cities. Urban areas areoften unhealthy places to live, characterized by heavy traffic, pollution, noise, violence and

social isolation for elderly people and young families. People in towns and cities experienceincreased rates of non-communicable disease, injuries, and alcohol and substance abuse,with the poor typically exposed to the worst environments.

Several epidemiological studies have identified the elderly and subjects with a pre-existingchronic cardiac or respiratory disease, congestive heart failure, and diabetes as subgroupsmore sensitive to the harmful effects of air pollution than the general population. This is alsothe case for children that may experience greater health effects due to the special sensitivityof their developing biological systems.
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Trends in Health in Europe and CA

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