Environment and Health

The European Charter

and Commentary
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ENVIRONMENT AND HEALTH
THE. EuROPEAN CHARTER
AND COMMENTARY
WHO Library Cataloguing in Publication Data
European Conference on Environment and Health (1st: 1989: Frankfurt)
Environment and health : the European Charter and commentary /
first European Conference on Environment and Health, Frankfurt,
7-8 December 1989

(WHO regional publications. European series ; no. 35)

I .Environment health- congresses [Link] policy- congresses

[Link] promotion - congresses [Link] [Link] [Link]

ISBN 92-890-1126-2 (NIM Classification: WA 30)

ISBN 978-92-890-1126-6
ISSN 0378-2255
Environment and Health
The European Charter
and Commentary

First European Conference

on Environment and Health
Frankfurt, 7-8 December 1989

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~~
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~

WHO Regional Publications

European Series No. 35
 ISBN 92-890-1126-2
ISBN 978-92-890-1126-6
ISSN 0378-2255

© World Health Organization 1990

Publications of the World Health Organization enjoy copyright protection in

accordance with the provisions of Protocol 2 of the Universal Copyright
Convention. For rights of reproduction or translation, in part or in toto, of
publications issued by the WHO Regional Office for Europe applications
should be made to the Regional Office for Europe, Scherfigsvej 8,
DK-2100 Copenhagen 0, Denmark. The Regional Office welcomes such
applications.
The designations employed and the presentation of the material in this
publication do not imply the expression of any opinion whatsoever on the part
of the Secretariat of the World Health Organization concerning the legal status
of any country, territory, city or area or of its authorities, or concerning
the delimitation of its frontiers or boundaries. The names of countries or areas
used in this publication are those that obtained at the time the original language
edition of the book was prepared.
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does not imply that they are endorsed or recommended by the World
Health Organization in preference to others of a similar nature that are not
mentioned. Errors and omissions excepted, the names of proprietary
products are distinguished by initial capital letters.
 Contents
Page
Foreword .. .. ............................. .... ..... .. ...................... ... ...... ... ix

THE [Link] ..... .... ... .. .. .. .. .. ..... .. .. .. ... .. .. .. .. .. .. .. .. ... .... ... .. .. .. ... . 1
Preamble .............................................................................. 2
Entitlements and responsibilities .. .. .. . .. .. .. .. .. . .. .. .. .. .. .. .. .. .. .. .. 4
Principles for public policy .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. ... . 6
Strategic elements ....... .. ... .. .. .. ...... ... .......... ....... .. .. .. .. . .. .. .. . .... 9
Priorities ...... ... ....... ... ............................. ......... ... ..... ...... ....... 12
The way forward .. .. .. .... .. .. .. .. .. ............ .... .. ... ... .. .. .. .. . .... . ....... . 14

THE Co:M:MENTARY .................................................................. 17

Introduction .............................. ..... ........................... ....... ..... 18
The nature of environmental health .. .. .. .. .. .. .. ... .. .. .. .. .. .. .. . 18
The pwposes of the Charter and the Commentary .. ...... 19
The preamble .. .. .. .. ... .. .. .. .. .. .. .. .. ... ...... ... .. .. .. ..... .. .. .. .. . ... ....... .. . 21
The dependence of health on environmental factors .. .. .. 21
Preventing health hazards by protecting
the environment ............. ..... .. . .. ..... .. .. ....... .. .. .. ... .. .. .... 22
A clean and harmonious environment for health
and wellbeing ............. ..... .. ....................... ... .. . ... ... ..... 22
Achiev~ments in pollutio~ abatement and
envrronmental restoratiOn .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. 23
The need for a sustainable system of development ... .. .. . 23
m-considered use of resources and products .. .. .. .. .. .. .. .. .. 24
The international character of environment
and health .. .. ..... . .. . .. ..... .. .... .... .. . .. .. ... .. . .. ........... .. ... .. ... 25
Problems facing the developing countries . .. ... .. .. ... .. .. .. .. . 26
The reasons for a Charter specific to Europe ... ..... ........ 26
Existing international instruments .. .. .. ... .... .. ...... .. .. ..... .. .. 27
Entitlements and responsibilities .. ........................... ... .. .. .... 28
The entitlements of the individual ....... .... ........... ... .... .. . 28
The responsibilities of the individual .................. .......... 31
An intersectoral responsibility for all sections
of society ............ .......................... .... ........ .............. .. 32
Cooperation with other sectors ........ ... ... ... ... .... .............. 33
International responsibilities of governments .............. 34
Protecting health ............... ... ...... .. ... ............................... 35
The role of the media .. .. .......... .. ............................ ........ 35
The role of nongovemmental organizations ............ ... ... 36
Principles for public policy ...... ............ .. .. ......... ... .......... ... . 3 7
The environment and health ............... .. ...... ... ................ 37
Giving priority to prevention ........................................ 39
Vulnerable and high-risk groups .................................. 40
The best available scientific information ...................... 41
The need for prudence .......... ........... .. ..... .. ............. ....... 41
Health takes precedence ...................................... ...... .. .. 42
Assessment of the impact of the environment
on health .................... .................. .... ..... ...... ............. 44
Optimal use of natural resources ...... ...... .... .. ................ 45
Preventing and reducing adverse effects ...................... 46
Environmental standards ..... .... ... .. .......................... .. ...... 48
The "polluter pays" principle ................. ....... ........ ...... 49
Monitoring and evaluating damage ........ ................ ... ... 50
Avoiding the export of environmental
and health hazards .................................................... 52
Development assistance ........................ ...... ... ... ........ .... 52
Strategic elements ............ .......... .................. ... .... .............. ... 54
Environment as a positive health resource .................... 54
Management ...... ..... .............. .. ............... .. ...... .. .. ............ 55
Responsibilities for implementation ........................ 55
Reducing risks to health .......................................... 56
 Meth?<fs of preven~ion ............. ........ ..... .......... ...... .. .. 57
Low-unpactstrateg1es ................................................ 58
Operational management ............ ............ .. ...... .......... 58
Regulations ................................................................ 59
Standards ......... .......... .................................... .... .. ....... 59
Strategies for chemical safety ............................... ..... 60
Contingency planning for accidents .......................... 62
Information systems ................... ........... ..... ............. .. 64
Impact assessment ...................................................... 65
The role of various disciplines in research
and management ................... .. ....... ...... ....... ... ......... . 66
Environmental epidemiology .................... ..... ... ............ 67
Epidemiological surveillance .............................. .. ... ..... 68
Training .................................. ... ............ .. ...................... . 68

Priorities ............ ................... ................................... ...... .. ...... 71

Priorities of special concern ..... .. .. ........ ................ .......... . 72
Global disturbances to the environment .. .......... ........ 72
Urban development, planning and renewal .............. 74
Safe and adequate drinking-water supplies
and hygienic waste disposal ... ..... ... ... .................. 75
Water quality .............................................................. 77
Microbiological and chemical safety of food ............ 78
Enviro~ental and healtJ:t impact
of vanous energy options ... ................... .. ..... ....... 81
Environmental and health impact
of road transport . . . .. . . . . . . . . . . . . .. . . . . . . . . . . . .. . .. . . . . .. . . . . . . .. . 82
Environmental and health impact
of agricultural practices ... .. ............ ... .................... 83
Air quality ... ..... ........................................ .. .. ..... ......... 84
Indoor air quality ...................................................... 86
Persistent chemicals and those causing
chronic effects ......................... ........ .. .. ................ . 88
Hazardous wastes ... ... .................................. ..... ......... 89
Biotechnology ............................................................ 90
Contingency planning for accidents
and disasters ..... ...... .. .............................. .. .... . ........ 92
Cleaner technologies ..... ........ ..... .. ... .. ................ .... . .... 93
 Intersectoral environmental planning
and community management ...................... .. .. .... .. .. 93
Health promotion .................... ............... ...... .. ............... 94
International cooperation .. ....... ... .................................. 9 5
The way forward ...... .................. ................ ............ ...... .... .. 98
International collaboration ............................................ 98
Indicators .. .. .. .. .. .. .. .. .. .. .. . .. .. ... .. .. .. .. .. .. ..... .. .. ............ .. ..... 100
European Advisory Committee on
the Environment and Health .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .... .. 100
European Centre for Environment and Health ............. 101
Promoting the Charter .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. 102
Follow-up Conference .. .. .. .. .............................. ............ 102

ANNEXES ...... .. .. .. ... ..... .. .. .. .. . ... ...... .. .. . ...... ... ... . ......... ... .. .. .. ... . 105
1. Relevant European Health for All Targets .. .. .. .. .. .. .. .. .. 106
2. Resolution 42/187 of the United Nations General
Assembly: Report of the World Commission
on Environment and Development .......................... 135
3. Resolution 42/186 of the United Nations General
Assembly: Environmental Perspective to
the Year 2000 and Beyond ...................................... 142
4. Resolution WHA41.15 of the World Health Assembly:
Report of the World Commission
on Environment and Development .......................... 149
5. Resolution WHA42.26 of the World Health Assembly:
WHO's Contribution to the International Efforts
towards Sustainable Development .. .. .. .. .. .. .. .. .. .. .. .. .. 151
Foreword
The First European Conference on Environment and Health,
held at Frankfurt-am-Main, Federal Republic of Germany
on 7 and 8 December 1989, brought together ministers and
other senior representatives from the environment and health
administrations of 29 European countries and from the
Commission of the European Communities.
The Charter, which was adopted by the final session of
the Conference, is a further extension of the European health
for all policy and targets adopted by the 32 Member States of
the European Region of WHO in 1984. The Charter also in-
corporates the basic philosophy of the World Commission on
Environment and Development, and represents a major step
forward in the development of both public health and en-
vironmental policies at a time when political change is
greatly enhancing cooperation among Member States
throughout Europe.
The present volume combines the Charter and the Com-
mentary, an explanatory text originally provided as back-
ground for delegations to the Conference. It is now being
more widely disseminated at their request.
Since this text was prepared, a major development in the
implementation of the Charter has taken place, in that an
agreement on the establishment of a European Centre for

ix
Environment and Health has been signed with the govern-
ments of Italy and the Netherlands. It is already clear that
governments are making use of the Charter as a basis for
practical action in the interests of all our citizens now and in
the future.

J.E. Asvall
WHO Regional Director for Europe

X
 THE
CHARTER
Preamble
In the light of WHO's strategy for health for all in Europe,
the report of the World Commission on Environment and
Development and the related Environmental Perspective to
the Year 2000 and Beyond (resolutions 42/187 and 42/186 of
the United Nations General Assembly) and World Health
Assembly resolution WHA42.26,
• Recognizing the dependence of human health on a wide
range of crucial environmental factors,
• Stressing the vital importance of preventing health
hazards by protecting the environment,
• Acknowledging the benefits to health and wellbeing that
accrue from a clean and harmonious environment,
• Encouraged by the many examples of positive achieve-
ment in the abatement of pollution and the restoration of
a healthy environment,
• Mindful that the maintenance and improvement of
health and wellbeing require a sustainable system of
development,
• Concerned at the ill-considered use of natural resources
and man-made products in ways liable to damage the
environment and endanger health,

2
• Considering the international character of many environ-
mental and health issues and the interdependence of
nations and individuals in these matters,
• Conscious of the fact that, since developing countries are
faced with major environmental problems, there is a need
for global cooperation,
• Responding to the specific characteristics of the Euro-
pean Region, and notably its large population, intensive
industrialization and dense traffic,
• Taking into account existing international instruments
(such as agreements on protection of the ozone layer) and
other initiatives relating to the environment and health,
The Ministers of the Environment and of Health of the
Member States of the European Region of WHO, meeting to-
gether for the first time at Frankfurt-am-Main on 7 and 8 De-
cember 1989, have adopted the attached European Charter
on Environment and Health and have accordingly agreed
upon the principles and strategies laid down therein as a firm
commitment to action. In view of its environmental man-
date, the Commission of the European Communities was
specially invited to participate and, acting on behalf of the
Community, also adopted the Charter as a guideline for
future action by the Community in areas which lie within
Community competence.

3
Entitlements
and responsibilities
1. Every individual is entitled to:
• an environment conducive to the highest attainable
level of health and wellbeing;
• information and consultation on the state of the en-
vironment, and on plans, decisions and activities
likely to affect both the environment and health;
• participation in the decision-making process.
2. Every individual has a responsibility to contribute to the
protection of the environment, in the interests of his or
her own health and the health of others.
3. All sections of society are responsible for protecting the
environment and health as an intersectoral matter in-
volving many disciplines; their respective duties should
be clarified.
4. Every public authority and agency at different levels, in
its daily work, should cooperate with other sectors in
order to resolve problems of the environment and health.
5. Every government and public authority has the responsi-
bility to protect the environment and to promote human
health within the area under its jurisdiction, and to ensure

4
 that activities under its jurisdiction or control do not
cause damage to human health in other states. Further-
more, each shares the common responsibility for safe-
guarding the global environment.
6. Every public and private body should assess its activities
and carry them out in such a way as to protect people's
health from hannful effects related to the physical,
chemical, biological, microbiological and social environ-
ments. Each of these bodies should be accountable for its
actions.
7. The media play a key role in promoting awareness and a
positive attitude towards protection of health and the
environment. They are entitled to adequate and accurate
information and should be encouraged to communicate
this information effectively to the public.
8. Nongovernmental organizations also play an important
role in disseminating information to the public and pro-
moting public awareness and response.

5
Principles for
public policy
1. Good health and wellbeing require a clean and har-
monious environment in which physical, psychological,
social and aesthetic factors are all given their due im-
portance. The environment should be regarded as a
resource for improving living conditions and increasing
wellbeing.

2. The preferred approach should be to promote the prin-

ciple of "prevention is better than cure".

3. The health of every individual, especially those in vul-

nerable and high-risk groups, must be protected. Spe-
cial attention should be paid to disadvantaged groups.

4. Action on problems of the environment and health

should be based on the best available scientific in-
formation.

5. New policies, technologies and developments should be

introduced with prudence and not before appropriate
prior assessment of the potential environmental and
health impact. There should be a responsibility to show
that they are not harmful to health or the environment.

6
6. The health of individuals and communities should take
clear precedence over considerations of economy and
trade.

7. All aspects of socioeconomic development that relate to

the impact of the environment on health and wellbeing
must be considered.

8. The entire flow of chemicals, materials, products and

waste should be managed in such a way as to achieve
optimal use of natural resources and to cause minimal
contamination.

9. Governments, public authorities and private bodies

should aim at both preventing and reducing adverse
effects caused by potentially hazardous agents and de-
graded urban and rural environments.

10. Environmental standards need to be continually re-

viewed to take account of new knowledge about the
environment and health and of the effects of future
economic development. Where applicable such stan-
dards should be harmonized.

11. The principle should be applied whereby every public

and private body that causes or may cause damage to the
environment is made financially responsible (the pol-
luter pays principle).

12. Criteria and procedures to quantify, monitor and evalu-

ate environmental and health damage should be further
developed and implemented.

7
13. Trade and economic policies and development assist-
ance programmes affecting the environment and health
in foreign countries should comply with all the above
principles. Export of environmental and health hazards
should be avoided.

14. Development assistance should promote sustainable

development and the safeguarding and improvement of
human health as one of its integral components.

8
Strategic elements
1. The environment should be managed as a positive re-
source for human health and wellbeing.

2. In order to protect health comprehensive strategies are

required, including, inter alia, the following elements:
• The responsibilities of public and private bodies for
implementing appropriate measures should be clearly
defmed at all levels.
• Control measures and other tools should be applied, as
appropriate, to reduce risks to health and wellbeing
from environmental factors. Fiscal, administrative
and economic instruments and land-use planning have
a vital role to play in promoting environmental con-
ditions conducive to health and wellbeing and should
be used for that purpose.
• Better methods of prevention should be introduced as
knowledge expands, including the use of the most
appropriate and cost-effective technologies and, if
necessary, the imposition of bans.
• Low-impact technology and products and the re-
cycling and reuse of wastes should be encouraged.
Changes should be made, as necessary, in raw

9
 materials, production processes and waste manage-
ment techniques.

• High standards of management and operation should

be followed to ensure that appropriate technologies
and best practices are applied, that regulations and
guidance are adhered to, and that accidents and human
failures are avoided.

• Appropriate regulations should be promulgated; they

should be both enforceable and enforced.

• Standards should be set on the basis of the best

available scientific information. The cost and benefit
of action or lack of action and feasibility may also
have to be assessed but in all cases risks should be
minimized.

• Comprehensive strategies should be developed that

take account of the risks to human health and the
environment arising from chemicals. These strategies
should include, inter alia, registration procedures for
new chemicals and systematic examination of exist-
ing chemicals.

• Contingency planning should be undertaken to deal

with all types of serious accident, including those with
transfrontier consequences.

• Information systems should be strengthened to sup-

port monitoring of the effectiveness of measures
taken, trend analysis, priority-setting and decision-
making.

10
 • Environmental impact assessment should give greater
emphasis to health aspects. Individuals and com-
munities directly affected by the quality of a specific
environment should be consulted and involved in
managing that environment.
3. Medical and other relevant disciplines should be en-
couraged to pay greater attention to all aspects of en-
vironmental health. Environmental toxicology and envi-
ronmental epidemiology are key tools of environmental
health research and should be strengthened and further
developed as special disciplines within the Region.
4. Interdisciplinary research programmes in environmental
epidemiology with the aim of clarifying links between
the environment and health should be encouraged and
strengthened at regional, national and international lev-
els.
5. The health sector should have responsibility for epidemi-
ological surveillance through data collection, compi-
lation, analysis and risk assessment of the health impact
of environmental factors and for informing other sectors
of society and the general public of trends and priorities.
6. National and international programmes of multidiscipli-
nary training, as well as the provision of health education
and information for public and private bodies, should be
encouraged and strengthened.

11
Priorities
1. Governments and other public authorities, without preju-
dice to the importance of problem areas specific to their
respective countries, the European Community and other
intergovernmental organizations, as appropriate, should
pay particular attention to the following urgent issues of
the environment and health at local, regional, national
and international levels and to take action on them:
global disturbances to the environment such as the de-
struction of the ozone layer and climatic change;
urban development, planning and renewal to protect
health and promote wellbeing;
safe and adequate drinking-water supplies on the basis
of the WHO Guidelines for drinking-water quality to-
gether with hygienic waste disposal for all urban and
rural communities.
water quality in relation to surface, ground, coastal and
recreational waters;
microbiological and chemical safety of food;
the environment and health impact of:
- various energy options
- transport, especially road transport

12
 - agricultural practices, including the use of fertilizers
and pesticides, and waste disposal;
air quality on the basis of the WHO Air quality guide-
lines for Europe, especially in relation to oxides of sulfur
and nitrogen, the photochemical oxidants (''summer
smog") and volatile organic compounds;
indoor air quality (residential, recreational and occupa-
tional), including the effects of radon, passive smoking
and chemicals;
persistent chemicals and those causing chronic effects;
hazardous wastes including management, transport and
disposal;
biotechnology and in particular genetically modified
organisms;
contingency planning for and in response to accidents
and disasters;
cleaner technologies as preventive measures.
2. In addressing all of these priorities, the importance of
intersectoral environmental planning and community
management to generate optimal health and wellbeing
should be borne in mind.
3. Health promotion should be added to health protection
so as to induce the adoption of healthy lifestyles in a clean
and harmonious environment.
4. It should be recognized that some urgent problems re-
quire direct and immediate international cooperation
and joint efforts.

13
The way forward
1. Member States of the European Region should:
• take all necessary steps to reverse negative trends as
soon as possible and to maintain and increase the
health-related improvements already taking place. In
particular, they should make every effort to implement
WHO's regional strategy for health for all as it con-
cerns the environment and health;
• strengthen collaboration among themselves and,
where appropriate, with the European Community
and other intergovernmental bodies on mutual and
transfrontier environmental problems that pose a
threat to health;
• ensure that the Charter adopted at this meeting is made
widely available in the languages of the European
Region.
2. The WHO Regional Office for Europe is invited to:
• explore ways of strengthening international mech-
anisms for assessing potential hazards to health as-
sociated with the environment and for developing
guidance on their control;
• make a critical study of existing indicators of the
effects of the environment on health and, where

14
 necessary, develop others that are both specific and
effective;
• establish a European Advisory Committee on the
Environment and Health in consultation with the
govenunents of the countries of the Region;
• in collaboration with the govenunents of the Euro-
pean countries, examine the desirability and feasibil-
ity of establishing a European Centre for the Environ-
ment and Health or other suitable institutional ar-
rangements, with a view to strengthening collabora-
tion on the health aspects of environmental protection
with special emphasis on information systems, mecha-
nisms for exchanging experience and coordinated
studies. In such arrangements, cooperation with the
United Nations Environment Programme, the United
Nations Economic Commission for Europe and other
organizations is desirable. Account should be taken of
the environmental agency to be established within the
European Community.
3. Member States of the European Region and WHO
should:
promote the widest possible endorsement of the prin-
ciples and attainment of the objectives of the Charter.
4. European Ministers of the Environment and of Health
should:
meet again within five years to evaluate national and
international progress and to endorse specific action
plans drawn up by WHO and other international organiz-
ations for eliminating the most significant environmental
threats to health as rapidly as possible.

15
 THE
COMMENTARY
Introduction
The Nature of Environmental Health
The Conference focused on all aspects of the relationship
between the environment and human health, a subject re-
ferred to by WHO as environmental health.
Environmental health comprises those aspects of human
health and disease that are determined by factors in the
environment. It also refers to the theory and practice of
assessing and controlling factors in the environment that can
potentially affect health.
Environmental health, as used by the WHO Regional
Office for Europe, includes both the direct pathological
effects of chemicals, radiation and some biological agents,
and the effects (often indirect) on health and wellbeing of the
broad physical, psychological, social and aesthetic environ-
ment, which includes housing, urban development, land use
and transport.
These two aspects of environmental health make dif-
ferent scientific and organizational demands but are parts of
a coherent whole. The programmes of the Regional Office
on environmental health include water supply and sani-
tation, air and water pollution control, solid waste man-
agement, chemical and food safety, radiation protection,

18
housing and settlements, and occupational health. The
Charter takes all these into account.

The Purposes of the Charter

and the Commentary
A Charter by which the governments of Europe have adopted
a united position on the basic principles, mechanisms and
priorities for further developing environmental health pro-
grammes should, in itself, help to ensure that the subsequent
actions of those governments are undertaken confidently
and decisively.
Several factors impede international collaboration in this
field, including:
- misunderstandings about the scope of the subject,
since in some countries the term environmental health
is not used or understood, and in others it includes
activities that vary widely in type and scope;
- conflicting views on the nature and extent of the harm
caused by environmental factors and on the benefits of
more stringent controls;
- severe limitations on the methods available for esti-
mating harm;
- a difficulty shared by organizations responsible for
various aspects of environmental health in Member
States in securing the collaboration of other govern-
ment sectors and society at large.
The Charter, and this Commentary, aim to suggest a
reasoned consensus where immediately practicable and to
indicate ways of overcoming these impediments in future.

19
 Historically, charters have tended to be grants of just and
due rights, privileges and powers. In modem times, they
have come to be used and regarded as statements of basic
principles and entitlements in public affairs. The WHO
Regional Office for Europe uses the term charter in this latter
sense. The entitlements referred to in the Charter comprise
the generally accepted public precepts of morality for health
and the environment to which an individual is entitled, rather
than strictly construed legal provisions or acts.
The European Charter has been introduced at a time when
the peoples of the European Region are demanding decisive
policies and programmes to control the interaction of en-
vironment and health. The Charter includes key principles
for meeting this challenge, and represents a mutual under-
standing and determination to succeed.

20
The preamble
The Dependence of Health on
Environmental Factors
The starting point for policy on health and the environment
is the recognition that, in principle, almost every aspect of
the environment potentially affects health for good or ill.
This applies not only to specific agents (microorganisms,
other biological entities, physical forces and agents, and
chemicals) but also to elements of the urban and rural en-
vironment: homes, workplaces, leisure facilities and the
main components of the natural world (the atmosphere, soil,
water, and many parts of the biosphere). A properly man-
aged environment is therefore essential, not only to improve
health but indeed to ensure human survival.
Although many environmental factors have the potential
to harm health, it does not follow that they are doing so.
Humans and the biosphere can coexist in reasonable har-
mony, and in many ways they do. There are important
exceptions, however, including indirect or long-term effects
that have only recently been revealed, as well as some long
recognized recalcitrant problems. It is not yet completely
dear how current trends in environmental management and
the use of resources will affect health. There are substantial
geographical differences in the incidence of disease (and of

21
positive health) that are not yet understood, although life-
style or genetic factors do not explain them entirely. Im-
portant unsuspected environmental causes of disease proba-
bly remain to be found.
Some of the important influences of the environment on
health are very difficult to determine by scientific study and
seem to be psychological in character. A beautiful country-
side, together with cities, towns and villages that represent
the flowering of humanity's cultural achievements, are vital
to many people's sense of health and wellbeing. Likewise it
is accepted that unpleasant environmental conditions have
many important negative consequences for physical and
mental health.
It is increasingly necessary to ensure that the environ-
ment created by humans is planned and managed strongly
and imaginatively enough to maximize its potential benefits
to health and wellbeing. This is why the Charter addresses
not only hazard control but the management of all aspects of
the environment.

Preventing Health Hazards

by Protecting the Environment
The Charter acknowledges the relationship between many
aspects of care of the environment and of health, and focuses
on the principles, mechanisms and priorities for action ap-
propriate to Europe.

A Clean and Harmonious Environment

for Health and Wellbeing
Policies are needed that promote positive enhancement of
the physical environment, so that it will not only be free from
22
obnoxious or offensive influences but also provide an ef-
fective and hannonious basis for healthy living. In this
respect, the Charter embodies some of the principles devel-
oped for the WHO Healthy Cities project.

Achievements in Pollution Abatement

and Environmental Restoration

Many cases of contamination or neglect of the environment

have been prevented or reversed by wide-ranging local,
regional, national or international programmes. Based on
present evidence, if the best practices already adopted in
some places were universally followed, the total impact on
health of unsatisfactory environmental conditions in Europe
would be much reduced. With few - though important -
exceptions, techniques are available to deal with the en-
vironmental health problems that have been clearly identi-
fied. The European Region faces a major challenge in
promoting the best practice and techniques more uniformly
throughout individual countries. The Charter is intended to
help in this process.

The Need for a Sustainable System

of Development
Sustainability is a strategy for socioeconomic development.
It implies meeting the needs of the present generation,
without compromising the ability of future generations to
meet theirs. It demands that development be pursued within
the constraints of the earth's resource base and the bio-
sphere's capacity, which some existing strategies cannot
fulfil. Sustainability requires new approaches and practical

23
measures, and reorientation at the highest political level, in
many sectors of society.

The European Region of WHO is now obliged to consider

sustainability in many of its environmental issues: for
example, the depletion of the stratospheric ozone layer, the
deterioration of large areas of the Mediterranean Sea, energy
production from low-quality brown coal, acid deposition,
groundwater pollution, some aspects of intensive agri-
cultural production, and urban transport policies.

All these issues significantly affect health. The Chair-

man of the World Commission on Environment and De-
velopment, Gro Harlem Brundtland, then Prime Minister of
Norway, stressed the interdependence of health and sustain-
able development in her 1988 speech to the World Health
Assembly. The questions addressed by the Charter are
therefore very important for the follow-up to the Com-
mission's report, which includes both the high-level con-
ference of industrialized countries in Bergen in 1990 and the
global conference proposed for 1992. Relevant resolutions
of the United Nations General Assembly and of the World
Health Assembly are presented in Annexes 2-5.

Ill-considered Use of Resources

and Products
Although most European countries have reasonably ef-
fective systems that prevent or reduce harm from recognized
categories of hazard, new and sometimes alarming problems
still occur. Some are essentially unpredictable, but experi-
ence in recent years shows that, outside closely regulated

24
fields, ill-considered land use, carelessness with resources,
poor hygiene, and thoughtless use and development of new
technologies, chemicals and products are commonplace. In
some fields and in some localities, grossly polluting tech-
nology continues to be used even though substantially su-
perior technology is readily available. The damage that
occurs to the environment and to health might easily be
foreseen and avoided. One main purpose of the Charter is to
defme and seek agreement on the required policy changes
and countermeasures.

The International Character

of Environment and Health

The programmes that protect and enhance health in relation

to the environment face many of the same issues in different
European countries, even if priorities vary. Much of the
necessary research, assessment and preparation of guide-
lines and codes of practice can therefore be accomplished
most effectively internationally. Nevertheless, flexibility is
essential to respond effectively to problems faced by par-
ticular countries or areas, taking into account differences in
their social and economic circumstances.

Some problems are basically international, such as the

pollution of air or water across national borders and inter-
national movement of food, consumer products, waste and
potentially hazardous chemicals. These problems require
specific international agreements and collaboration, and the
Charter supports such initiatives in the context of protecting
health.

25
Problems Facing
the Developing Countries
In many developing countries, environmental problems have
grown to dimensions that may exceed those of countries that
have been industrialized for many years. Pollution, land-use
practices, agriculture (including overgrazing and deforest-
ation), rapid and uncontrolled urbanization, and inap-
propriate use of water resources frequently cause particular
problems that can often be correlated with serious health
detriments.
The influence of economic policies and of technological
innovations from the developed countries, including those
of the European Region, have contributed to these problems
in some cases. The resulting effects can transcend national
boundaries and, in some cases, can have global con-
sequences. International cooperation is therefore needed,
and the European Region is in a strong position to lead such
initiatives.

The Reasons for a Charter

Specific to Europe
Many of the principles and proposals set out in the Charter
for Europe also apply to other parts of the world; in some
ways, parts of the European Region have more in common
with countries outside Europe than with other European
countries. Nevertheless, Europe has a particular character
stemming from its generally high population density, in-
tensive industrialization, transport problems, urbanization,
cultural identity, the interdependence of its 32 countries in

26
resources and trade, the generally high level of socio-
economic development, and the increasing mobility of its
population. For these reasons, the Charter has been de-
veloped primarily to conform to the specific circumstances
and needs of the European Region; if it leads to more
widespread action, so much the better. In the light of
changing circumstances, it was thought constructive to build
on common perceptions across the entire Region of what is
required in terms of environment and health policy, since
collaboration between the different political and economic
groups in Europe is at least as necessary in this field as
collaboration within each separate group.

Existing International Instruments

There are many examples of international collaboration;

some of these were referred to earlier. Any new initiative
emerging from the Conference must clearly build, if
possible, on existing arrangements and not seek to duplicate
them.

27
Entitlements
and responsibilities
The Entitlements of the Individual
The concept of a human entitlement in relation to health
must be defined carefully to be of value. An entitlement is
something a person expects in a defined area, based on law,
morality or traditional social practice. Certain entitlements
can be construed as specific rights and are enforceable in
their nature and may be provided for by law. Nevertheless,
such broadly conceived entitlements as the right to health,
which was included in the United Nations Declaration of
Human Rights, or the right to an environment conducive to
health, are not precise in their practical implication, nor are
they anyone's gift to provide in any absolute sense. They
reflect a shared moral view of society, a touchstone against
which the appropriateness of specific policies and actions
can be tested and, if necessary, provided for by law.
The public acknowledgement of generally recognized
and morally based entitlements of individual people in re-
lation to environmental health programmes may help to
re-establish trust in public policy which, reasonably or not,
has been damaged in some ways in recent years. People's
legal entitlement to redress if they can prove that damage
results from the action of others is well established in
national legal systems. The public, however, now has a

28
strong sense that it is entitled to the protection of health
(where possible by preventive action) that limits the likeli-
hood or extent of risk from environmental hazards; and to be
informed and consulted on the state of the environment and
on plans, decisions and activities likely to affect the environ-
ment and health, including participating in the decision-
making process.
These entitlements also extend to any person whose
health is damaged by the action of any other person, not only
the state or others in authority. The Charter acknowledges
that every individual is entitled to an environment conducive
to health. Every individual also shares the responsibility for
securing good health within the environment, and cannot
merely depend on others for protection.
Such an entitlement cannot be absolute: total absence of
risk is not possible. Health-enhancing improvements to the
environment would be unlimited if resources were un-
limited: this entitlement, however, can only extend to what
is practicable.
Experts and the public can perceive risk in radically
different ways. Public perception of a risk may prevent the
implementation of policies that experts (after careful study)
believe to be safe: for example, methods for disposing of
low-level radioactive waste. On the other hand, particularly
if they will suffer financially, people sometimes discount
risks that, for good reasons, experts take seriously. On other
occasions, the experts fail to foresee (or to acknowledge) the
likely hazards of a new technology or development that
the public reasonably objects to once they learn of it: for
example, some modem practices in the animal feedstuff
industry.

29
 People dislike being kept ignorant or discovering that an
official body is so sure that it knows best that it is unwilling
to listen to other opinions. Implementing an entitlement to
know in the terms used in the Charter inevitably has dis-
advantages, as it will arm people who are stubbornly deter-
mined to oppose some new technology or development. It is
reasonable to expect, however, that ready access to in-
formation will reinforce trust and most people's willingness
to accept well argued policy, at least in the longer term.
The public should be entitled to information that is
gathered for management purposes or as a legal obligation.
Nevertheless, categories of information such as commercial
secrets may have to be excluded, although it is questionable
whether all information currently kept secret merits such
protection.
Collecting, analysing and disseminating information is
costly. Data must be selectively gathered. The public
particularly needs information on developments and prod-
ucts that may affect health and on the effectiveness of
control measures. On the other hand, to take a sensible view
of the public interest, an entitlement can only comprise what
it is practicable to obtain.
The WHO Healthy Cities project has shown the value of
public participation in complex projects in which the com-
munity has as much to give as to gain in improving its own
environment. The authorities may find it very difficult to
consult the public, for example on a proposed waste disposal
facility, when the local community feels that it is being asked
to accept some risk to benefit people living in a much wider
area. In an open society, however, failure to consult is likely
to cause even bigger problems. People feel strongly that

30
they have the right to be consulted when their interests are
affected, and this should not lightly be ignored.
The way forward, based on the difficulties participation
and consultation can produce, is for experts to acknowledge
the roots of public concern, and to balance this by dis-
seminating more information to the public. More public
knowledge of potential environmental hazards and of the
means used to assess and mitigate the risks associated with
them should lead, in time, to more reasonable attitudes.

The Responsibilities of the Individual

Most people will agree that they have an entitlement to an
environment conducive to health. They may be less ready to
accept voluntarily that there are balancing obligations, but
the human race cannot afford to have social groups that
continue to be irresponsible. Care for a health-giving envi-
ronment cannot be regarded merely as a virtue; it is an
obligation. The more this care is accepted as a freely
undertaken moral obligation the better, although it needs to
be supported by a framework of law and effective enforce-
ment. It is, of course, easier to propose that every person is
responsible for a health-giving environment than to bring
about the changes in attitude required to implement this
principle. This is the challenge.
The entitlements of individuals do not exist without
corresponding responsibilities, not only to protect the safety
of others but to help promote a safe, health-enhancing
environment for the community. Moreover, the individual
is responsible to more people than those encountered from
day to day in the immediate environment; public policies

31
designed to promote the health and wellbeing of future gen-
erations and the inhabitants of other countries need the
assent and sometimes the active participation of individual
people. Individuals are also responsible for the quality of the
urban, rural and natural environments because they signifi-
cantly influence health and wellbeing.

An lntersectoral Responsibility
for All Sections of Society
The Charter contends that it falls to all sections of society,
including every individual, group and organization, to ex-
ercise a duty for care to a healthy environment when going
about their affairs. Unless special care is taken each person,
group and organization, often without realizing it, tends to
degrade the environment, to deplete the earth's resources
and to infringe the entitlements of others. Activities outside
the purview of health professionals, public health authorities
and the regulatory agencies have caused many serious en-
vironmental health problems in recent years. The nature of
environmental health is that hazards may appear in con-
nection with virtually any human activity. To reduce en-
vironmental hazards and to enhance environmental quality,
the people responsible for each activity must exercise care
and foresight in the first place; they are usually the only
people who fully understand it technically. Environmental
health, therefore, is the responsibility of all sections of
society.
Potential hazards to health are caused by agents from
many sources, which reach humans by complex routes.
Hazards with which one sector of society must cope, such as
the water supply and food industries, may originate in the
practices of another, such as agriculture. The most effective

32
solution requires the cooperation of all sectors involved, and
optimal progress depends on collaboration, not on the de-
fence of sectoral interests. Environmental health is thus not
just multisectoral but also an intersectoral responsibility.

Cooperation with Other Sectors

Isolated decisions cannot usually solve problems of environ-
ment and health; a lack of cooperation between authorities
has created .or aggravated many problems. Mechanisms for
intersectoral cooperation must be established for policies
(such as those relating to energy, transport and agriculture),
for strategic and physical planning and for individual devel-
opments. Environment and health considerations need to be
addressed at the earliest possible stage, in accordance with
the principle of prevention.
In some cases intersectoral collaboration may have to be
mandatory; in others it may be effectively achieved by
establishing less formal consultative mechanisms. The
Healthy Cities project has demonstrated how this process
can operate at the municipal level: it needs to be applied
locally, regionally, nationally and internationally.
Such collaboration involves interests whose objectives
may be diametrically opposed. It is therefore difficult, but
collaboration is fundamentally important to achieving satis-
factory environment and health conditions and a process of
sustainable development.
Individual European countries vary considerably in the
way they delegate the responsibility for environmental
issues as a whole, and for health aspects of the environment,
among government departments and agencies. Regardless
of the system adopted, the many possibilities for interaction

33
between the policies of the health and environment sectors
and others require both effective collaboration and very
clear mutual global objectives.
An important question is whether the political responsi-
bility for major socioeconomic development sectors should
lie in the same hands as the responsibility for protecting
human health and the environment. On the one hand an
organization with dual responsibility, either national or lo-
cal, risks subordinating protection to socioeconomic devel-
opment. On the other hand environmental protection and
health agencies at all levels are liable to be held publicly
responsible for any evidence that the authorities as a whole
have failed to protect health or the environment, although
they may not have either the means or the power to be aware
of potential problems or to take appropriate action. More-
over, separation of functions may tempt people responsible
for socioeconomic development to neglect their obligations
towards health, environmental protection, conservation and
sustainability.
The choice of structure is probably less important than
having clear overall objectives. The short-term tensions be-
tween environmental health and economic objectives should
be openly acknowledged, and there should be intersectoral
links with clearly delegated responsibility and public ac-
countability to make sure that these links are effective.

International Responsibilities
of Governments

All countries share a vital responsibility for preventing

catastrophic damage to the global environment and thus to

34
humanity. Each country has the responsibility to ensure that
activities under its jurisdiction or control do not damage the
health of humans in other countries through pollution, trade
in hazardous materials or other causes.

Protecting Health

In order that socioeconomic development and innovation

proceed in a way that protects and, where possible, enhances
human health, the effects of whatever is planned need to be
predicted, so that rational decisions can be made. The
process of environmental impact assessment is now be-
coming a generally accepted tool for specific developments,
and effects on human health must clearly be taken fully into
account. Technology and products should be routinely
assessed, to improve the health and safety of workers,
consumers and the general public. Whereas much progress
has been achieved in assessing potentially hazardous chemi-
cals, the effects of changes in such diverse fields as housing
construction, transport policies and food production and
manufacture have not been consistently taken into account.
A process of accountability to competent and specifically
designated authorities must be built into such systems of
impact assessment.

The Role of the Media

The average person cannot be expected to evaluate every

facet of environmental quality as it relates to health, or the
adequacy of work carried out by private and official
agencies. The media and special interest groups can perform

35
a vital function by obtaining and interpreting information for
the public. As the truth about a pollution incident is often
dull, however, journalists may be tempted to create colour-
ful, unjustifiably alarming stories or to emphasize unduly
the extreme views of individual experts. Official agencies
get angry when this happens, particularly if they are not
consulted. Nevertheless, it is useless for them to complain if
they do not provide the media with honest and effective
information. A compact is needed between the two sides.
Journalists should be briefed as fully and accurately as
possible, and they should be encouraged to communicate
this information effectively to the public. Neither conceal-
ment nor false scares are in the public interest.

The Role of Nongovernmental

Organizations

A wide range of nongovernmental organizations has demon-

strated an awareness of and concern for environmental and
health issues in the European Region. Some organizations
were specifically established based on those issues at local,
national or international level; others include such issues as
part of their wider terms of reference. Together, in their
different ways, they represent a sizeable proportion of
the total population and this potential should be fully used
for consultation, and for providing and disseminating in-
formation.
The cooperation of such organizations, whether con-
cerned with professional, commercial, or community or
other interests, is essential to promote and to achieve an
improved environment for human health and wellbeing.

36
Principles for
public policy
The Environment and Health
A basic concept of the Charter is that environmental health
in Europe includes not only pollution control and environ-
mental hygiene but all aspects of the physical environment
and of socioeconomic development.
The difficulties facing planners in relation to the latter as-
pects are exactly the opposite of the difficulties involved in
chemical and radiation hazards, where much is known on how
adverse effects might occur but, in many cases, it is not known
whether they do occur. For the physical environment,
substantial geographical differences in the incidence of dis-
ease clearly coincide with different housing standards and
urban and rural conditions in health statistics, although the
precise causes and mechanisms are not known. However,
the public health reforms of the nineteenth century suggest
that remedying conditions that are perceived as poor or
stressful is very effective in reducing high disease rates, and
can indeed lead to an understanding of the etiology even in
the absence of prior scientific evidence. It is true that there
are lifestyle and probably genetic factors in the geographical
differences in disease incidence, but it is also increasingly
clear that a range of environmental factors, and the inter-
action between those and lifestyle, are of great importance.

37
 It is not, of course, intended that expensive changes in the
built environment are justifiable solely because of general
speculation about their supposed effects on health. Recent
experience, however, such as that of the Healthy Cities
project, shows that carefully analysing the problems of
individual communities can lead to many economically
realistic initiatives that can be implemented when public
enthusiasm, including that of businesses and official
agencies, is harnessed to promote changes that clearly ben-
efit health and wellbeing. The mechanisms behind the
record of poor health in certain communities need to be
revealed by precise, painstaking scientific study, but major
health problems should not be neglected just because their
causes are difficult to trace. As in the case of individuals
with poorly understood illnesses, faith, enthusiasm, a will-
ingness to experiment and care in listening to the individual
or to the community are all necessary.

The features of the physical environment that are un-

questionably responsible for illness, injury and death must
be given high priority. Accident prevention, for example,
needs to be strongly emphasized in designing housing, trans-
port systems and the workplace. It is imperative to remedy
the insanitary conditions still widespread in the home and
community and in food production and handling. Urban
facilities and infrastructures that are clearly linked with
health, such as attractive, affordable facilities for healthy
recreation, are another good starting-point for collaboration
among sectors.

It is not only the physical aspects of the environment that

influence health, but also the psychological, social and
aesthetic dimensions. People usually feel fitter and happier

38
when their surroundings are attractive and when their neigh-
bours are friendly and well behaved. Conversely, psycho-
logical and social factors affect physical symptoms and
contribute to psychiatric disorders, although their role in
causing physical disease is more controversial. Whatever
the case, WHO's definition of health is broad: "health is a
state of complete physical, mental and social wellbeing and
not merely the absence of disease and infirmity."

Many diverse professions and local, provincial and cen-

tral organizations are involved in physical planning and in
providing services for urban and rural environments. It does
not matter who provides the leadership as long as the health
dimension is explicitly regarded as a major objective and
taken fully into account at all stages.

Giving Priority to Prevention

In most cases, preventing ill health should take priority over

cure, and the most effective way to manage the environment
is to identify problems as early as possible and introduce
appropriate safeguards. In view of the principle of sustaina-
bility, proposed socioeconomic development must explicitly
address the need to minimize detriment to health and to
maximize health benefits by, for example, using low-impact
technologies in industry, agriculture and energy production,
and introducing appropriate land-use and transport policies.

Cleaning up the environment after long-standing pollu-

tion and correcting mistakes, for example in physical plan-
ning and in the design and construction of housing, are often
difficult and highly wasteful of resources.

39
Vulnerable and High-risk Groups
Individuals and groups who are at high risk need special
consideration. People working with certain processes or
living near certain industrial plants may be particularly
exposed to specific agents. Somewhat higher levels of risk
may be acceptable in the workplace than in the general
environment, but risk should be reduced to negligible levels,
except for people who choose to work in hazardous environ-
ments knowingly and without duress, when all possible steps
have been taken to minimize the risk entailed.
Infants and children tend to be at greater than average risk
for many reasons. They take in more of a contaminant
relative to their size than do adults, they have immature and
therefore vulnerable physiologies and, simply because of
their youth, have a greater probability of manifesting long-
term effects. Elderly people are also liable to certain physio-
logical vulnerabilities. Pregnant women and mothers re-
quire special consideration, not only to maintain and im-
prove their own health but because they pass contaminants
to the fetus and to breastfed infants.
The needs of these vulnerable groups should normally
determine the limits to be applied to the whole population,
but if this is not possible, special steps should be taken to
protect these groups.
The vulnerability of individuals also varies: safety fac-
tors used for setting control limits provide for a range of
susceptibility to hazardous agents. Individuals who, be-
cause of sensitization or pre-existing illness, are vulnerable
to agents that are harmless to most people present a more
difficult problem. Care must be taken in permitting the use

40
of substances liable to sensitize, and general restrictions are
needed when many people are vulnerable. There is, how-
ever, a limit to what is practicable, and some people must be
protected individually.

The Best Available Scientific Information

The need to strengthen information systems is addressed on

page 64. In some cases, sufficient information is not avail-
able to make rational decisions, either because the in-
formation does not exist or because it is not accessible. In
other cases, information (such as environmental monitoring
data) may be available, but is irrelevant for the intended
purpose. Appropriate information of many kinds from a
wide variety of sources needs to be generated and used
optimally. This requires carefully defining the requirements
of the environment and health and a high degree of cooper-
ation among the different authorities involved.

The Need for Prudence

There is considerable uncertainty about the extent of direct

and indirect risks to human health caused by specific agents
present in the environment. For many substances, it is not
known whether there are thresholds to an adverse effect or,
if so, what those levels are. The potential for harm of the full
range of chemicals to which people are exposed has not been
fully explored; there is clearly room among the burden of
unexplained disease for the operation of hitherto un-
suspected toxic effects. Substances widely present in food
and the environment that were once regarded as entirely safe
have turned out to have a propensity for harm, and probably

41
in future there will be other, similar unforeseen instances.
Further, there is at present limited knowledge of the pattern
in the general population of exposure to even well studied
toxic substances, or of the patterns of contamination of
water, food and indoor and outdoor air. Comprehensive
assessment of the separate or combined impact of all indi-
vidual chemicals is impracticable and will continue to be so.
The existing evidence on industrial discharges and on the
concentrations of chemical contaminants and radioactivity
in food, water and air and in the home and urban environ-
ments suggests that their total contribution to the burden of
disease in the general population is probably minor in most
communities, unless control measures have been grossly
neglected. Nevertheless, because this assessment is based
on substantially uncertain evidence that is inherently dif-
ficult to resolve, and because even small benefits to health
are desirable, a prudent policy on the levels of exposure per-
mitted for chemicals and radiation originating from human
activities continues to be important. Care is also sensible in
relation to natural substances, since they quite commonly
generate toxins. The public attitude towards risks associated
with pollution, as discussed earlier, reinforces the necessity
for a prudent policy in chemical safety and radiation
protection.

Health takes Precedence

Measures to increase protection from chemical, radiation

and microbiological hazards, and the creation and main-
tenance of an environment conducive to health, cost money.
Due weight should be given to such factors as the disincen-
tives to innovation implicit in a highly regulated system, and

42
in the direct costs (reflected by increased prices) or taxation
rates. Sound environmental health policies have economic
and health benefits, of course, and a long-term view on the
part of businesses and government sometimes implies a
greater investment in safety. The principles of sustainable
development demonstrate the increasing convergence of
economic, environmental and health goals. Nevertheless,
unjustifiably stringent standards can sometimes be paid for
only at the cost of health protection or health care or other
aims of society. No country can afford perfection. Prudent
objectives in environmental health and financial prudence
must be balanced.

There is controversy at present as to how those respon-

sible for environmental health should take account of costs
to industry. Some people believe that the regulatory agencies
should press for the cleanest technologies and minimal
discharges in all cases. They consider that if decisions on the
use of a particular agent or the control of a discharge depend
in part on the cost and technical feasibility of the change,
then adequate information is needed on the alternatives and
their cost. Such information is not readily available to the
regulatory agencies: technical knowledge usually lies with
the industries whose commercial interests are at stake and
much depends on whether industry will provide balanced,
complete information even when it is economically dis-
advantageous to do so. Cost predictions often turn out to be
inaccurate. Many changes, such as the introduction of lead-
free petrol, have been strenuously resisted for technical and
cost reasons (often· by government departments of industry
and finance and by industry itself) but then introduced
with relative ease. For these reasons, environmental
health professionals tend to be sceptical about the validity of

43
arguments that a given cleaner technology is not feasible at
acceptable cost. They are in a very weak position to sustain
an argument against scientists employed by industry; they
therefore often prefer to demand clean technologies and
minimal discharges as the norm and to resist the routine
application of a condition of practicability, judging that if
reductions are truly unfeasible at sustainable cost this will
rapidly become evident.
Nevertheless, controls should be applied on a rational,
informed basis, taking account of honest and accurate as-
sessments of what is technically achievable and what costs
are reasonable based on the advantage gained. In efforts to
enhance health while avoiding fruitless or unsustainable
pressures on the economy, everyone has a long-term interest
in dispassionate analysis and assessment based on the cri-
terion that the health of individuals and communities should
take clear precedence over considerations of economy and
trade.

Assessment of the Impact

of the Environment on Health

The mere existence of a system for routine assessment of

chemicals often leads producers to decide not to proceed
with the development of particular products. Other items do
not gain approval even before their existence is widely
known to the public. Thus the successes of the system can go
unnoticed.
The failures of environmental health protection have
been based partly on the failure to foresee the potential for
hazard in physical developments and new technologies. It

44
could be asked whether enough foresight has been used to
identify new classes of potential hazard. Could the effects of
chlorofluorocarbons on the stratospheric ozone layer have
been predicted? Could food poisoning caused by Listeria
have been foreseen as a consequence of the widespread use
of refrigeration?
Impact assessment is used increasingly to predict the
effects on the environment of new physical developments
such as industrial plants, dams and highways. Assessments
of health impact need to be explicitly incorporated in such
studies when appropriate. They must be carried out prior
to decision-making and as early in planning as possible. H
the development proceeds, it should be followed by care-
fully designed monitoring and evaluation programmes, with
appropriate legislation to ensure that controls are enforced.
The principles of environmental and health impact as-
sessment can also be applied to policy formulation: for ex-
ample, in developing strategies for alternative energy, trans-
port or food production. They may also be applied to
physical and economic planning at the earliest possible
stages of development.
Finally, impact assessment should be used more often for
new technologies that may significantly affect human health
and wellbeing.

Optimal Use of Natural Resources

The report of the World Commission on Environment and

Development emphasizes the need to ensure less wasteful
use of natural resources in the interests of sustainable devel-
opment. Contamination of the environment by industry can

45
be minimized not only by pollution control but by, for
example, prudently selecting raw materials and processes,
by recycling and re-use, and by developing by-products.
Steps must be taken not only in relation to individual in-
dustrial or other installations, but also at policy level. For
example, decisions on subsidies for nitrogenous fertilizers
could significantly influence a range of environmental
issues, yet only recently have such factors been taken into
account.
The ability to demonstrate the potential consequences of
particular policies, strategies and activities now seriously
challenges environment and health authorities. Modelling
the flow of chemicals, materials, products and waste in
alternative development scenarios becomes a high priority,
particularly within the densely populated and highly de-
veloped European Region, m order to allow rational
decision-making.
The principles embodied in this clause are a vitally
important component of preventive action.

Preventing and Reducing

Adverse Effects

Much of modern regulatory toxicology and radiation pro-

tection is already carried out very prudently. Food and en-
vironmental standards are usually based on very substantial
safety factors that are designed to allow for uncertainties or
statistical weakness in the evidence and for the possibility
that humans may be more susceptible than are the laboratory
animals used to derive a particular standard. Regulation of
carcinogens, for most of which no completely safe dose is

46
assumed, is based on the concept that some extremely low
level of predicted risk is acceptable. The exposure as-
sociated with this acceptable risk is estimated from animal
experiments by statistical procedures that tend greatly to
overestimate risk, because they are based on extremely
conservative assumptions.

These precautions mean that a moderate breach of any

particular standard is likely to have no effect. Safety mar-
gins are more narrow, however, for the limits set for some
contaminants already widespread in the environment, such
as lead or nitrate. It would be prudent to ensure that pro-
posals for regulation openly distinguish between cases in
which a narrow safety margin is considered to be fully
justified by toxicological evidence and criteria and cases in
which a narrow safety margin has to be adopted because it is
impracticable to employ more ample safety margins.

In regulating industrial discharges, in addition to specific

limits for selected substances, it is commonly required that
installations (to use two of the various terms in use) employ
the Best Available Technology Not Entailing Excessive Cost
(BATNEEC) so as to achieve discharges that are As Low As
Reasonably Achievable (ALARA).

It is here suggested that the general principle of seeking,

within reason, to minimize potential harmful exposure be
applied more widely. It should be a principle of environ-
mental health to avoid the use of or exposure to hazardous
agents for no good reason in unnecessary amounts or in
inappropriate ways.

Where applicable, standards should be harmonized inter-

nationally, as is already the case for many foods, food

47
additives and contaminants, including limits for pesticide
residues covered by the provisions of the Codex Ali-
mentarius.

Environmental Standards

Rational environmental standards to safeguard human health

must include appropriate safety margins, depending on the
nature of the potential hazard and its propensity for harm. At
present, risk is estimated in different ways in, for example,
chemical safety and radiation protection; more consistent
approaches would be advantageous.
There is a growing tendency for standards to be imposed
at national or even multinational level, and care must be
taken to ensure that this does not unduly distort local priori-
ties for environmental health protection.
For some potential health hazards, such as exposure to
lead, new scientific knowledge of health effects has led to
the necessity for progressively more stringent standards. In
other instances, research may show that particular standards
are unnecessarily restrictive.
Increased economic activity both within and beyond the
European Region will inevitably require stricter controls. If
the number of motor vehicles markedly increases, the emis-
sion standards will need to be appropriately reduced to
maintain the same ambient air quality. Unless they are
banned or stringently controlled, nondegradable con-
taminants will progressively accumulate over the years and,
m some cases, represent an increasing potential threat to
human health.

48
 Although some environmental standards will therefore
inevitably need to be progressively adjusted, regulations
should be stabilized over reasonable time periods, commen-
surate with protecting the environment and health.

The "Polluter Pays" Principle

It is being progressively accepted in most countries in
Europe that environmental policies and actions should re-
flect a number of underlying principles to which all public
and private bodies should adhere. One of the most important
principles is that the polluter should pay the cost of prevent-
ing, eliminating and disposing of pollution. This has proved
to be successful not only in controlling existing pollution but
in promoting the development of processes that pollute less.
Human health considerations should be fully taken into
account in applying this principle.
Such approaches may be widened to influence the course
of overall development towards sustainability for natural
resources, the environment and health. Endeavours are now
growing to assign monetary values to many aspects of
environmental quality, and it is increasingly acknowledged
that environmental quality is not free. The same economic
principles underlie the appropriate pricing of goods and
services and of natural resources: prices should reflect
the true social cost of production and use. Using prices in
this way is fully consistent with the principle that the pol-
luter pays.
In some circumstances, policy-makers might consider
supplementing the traditional approach to environmental
policy of setting standards with market-based approaches,

49
requiring payment and granting tradable permits. Con-
siderations of human health and its sustainability need to
remain paramount in all decisions on the environment and
socioeconomic development.

Monitoring and Evaluating Damage

The criteria and procedures for monitoring and evaluating
damage to the environment and to health are inadequate at
present.

Many environmental data are collected to assess com-

pliance with standards or guidelines, with the aim of detect-
ing peak levels, often at places that are not important in
terms of human exposure. Monitoring networks usually
provide, at best, only dense coverage for a few areas and for
a few substances. Often only a few of the potentially toxic
components of an emission are monitored for pollution, to
ensure that the controls are operating correctly. When
exposure is calculated, it is often carried out using statistical
modelling based on these emission data, and the results
inevitably include substantial uncertainty. The exposure of
the population to contaminated food or air is usually as-
sessed by ad hoc surveys rather than by routine monitoring.
Analytical procedures are sometimes inadequate and often
extremely costly.

The availability of useful data on health outcome is also

severely limited. Detailed mortality data should be available
in most European countries, although in some cases they are
not available for analysis for reasons of privacy. The at-
tributed causes of death are often inaccurate; but mortaJity
data often inaccurately indicate the incidence of disease

50
anyway, since much disease is not fatal or can be treated
successfully, or death is long delayed. Reasonably accurate
incidence data are available only for cancer, and then only
for some European countries.
At present, data on health outcome tend to be available
only for large geographical areas that are not usually the
focus of exceptional exposure to environmental contami-
nation. To investigate exceptional contamination, statistics
must be available for very small areas, which is the case in
only a few European countries. This type of study is
complex and time consuming, although there have recently
been some notable successes.

Data on health outcome related to microbiological con-

tamination of food and water have their own limitations.
Infections that are severe and even threatening the lives of
vulnerable people may be trivial for others. In many cases,
even individuals who suffer severe short-term discomfort
either do not receive medical attention or are not given a
specific diagnosis. Further systems for reporting diagnosed
cases are often informal. Incidence is thus often grossly
underestimated.
There are yet other obstacles to analysing data on health
outcome together with data on pollutants or other health
hazards in order to detect previously unrecognized effects,
that is, causes of disease. Ha chemical is the only cause of
a particular disease, the relationship is relatively easy to
detect. Environmental toxicology much more often faces
the situation, however, that a chemical may somewhat in-
crease the risk of a common disease that has many causes.
As a result, although differences in the incidence of a disease
in different communities may be associated with differences

51
in the level of exposure to a specific chemical, they may in
fact be caused by other factors. Similarly, it may be very
difficult to link unsatisfactory factors in the physical en-
vironment with specific health effects.
This subject is further addressed on page 64.

Avoiding the Export of

Environmental and Health Hazards

This clause affirms that countries should observe the prin-

ciples of this section of the Charter in their foreign trade and
economic policies and development assistance. Many
measures have already been taken to control the transfer of
potentially hazardous goods and wastes between countries,
and these will need to be progressively reinforced. It is
sometimes difficult to identify both the nature and extent of
the hazard, because the materials involved have been in-
adequately categorized.

Development Assistance

The report of the World Commission on Environment and

Development states that human health is an essential compo-
nent of and prerequisite for sustainable development. The
preamble of the Charter asserts that maintaining and improv-
ing human health and wellbeing require a sustainable system
of development. These considerations have clearly been
reflected in World Health Assembly resolution WHA42.26
(Annex 5).

52
 It is therefore appropriate for the Charter to affmn as a
principle of public policy that development assistance, as
one of its integral components, should promote sustainable
development and safeguard and improve human health.

53
Strategic elements
Environment as a Positive
Health Resource
Although the industrial revolution generated a dream of a
future in which humanity would "conquer" nature and
banish want and disease, development has had negative
effects, including new health hazards and stresses to the
environment often resulting from scientific and technical
advances. The relationship between people and the environ-
ment is now a major public concern throughout Europe: a
new principle of greater harmony between human activities
and the ecosystem is taking over from the previous attitude
of confrontation. Extreme approaches to both environ-
mental protection and socioeconomic development threaten
human health and wellbeing because they risk either under-
providing the means of life or overexploiting resources.
The Charter is based on the assumption that, by carefully
assessing their experience and the options before them, the
people of Europe can find the right way forward. The
science of environmental health should not only identify and
control hazards in the environment but also positively pro-
mote and enhance health by creating environmental con-
ditions that help individuals to improve their health and their
physical and mental wellbeing.

54
 Although specific hazards to health in degraded environ-
ments must be identified and corrected, most of the indi-
vidual features of such an environment, by themselves,
cannot be shown to adversely affect health: the total impact
is important. This is why the widespread deterioration that
characterizes many European towns and cities must be re-
versed. Individuals and the community must help with the
work, to break down barriers and overcome inertia.

Management
Responsibilities for implementation

How much responsibility should be vested at central, provin-

cial or local government level for the detailed implementa-
tion of pollution control and other environmental health
policies?
There are many options, each with its own drawbacks.
Decentralized structures may lack the resources necessary to
manage all the complex components of environmental
health, and may not be committed to self-regulation. They
may introduce conflicts and inconsistencies into problems
such as food safety and pollution control as they transcend
local boundaries. On the other hand, highly centralized
structures are liable to generate complex regulation and
monitoring systems, whose operations can too easily be-
come divorced from the reality of the problems faced by
those working in the field, lose touch with community
opinion, and start wasting resources.
Whatever structure is chosen, the roles and responsibili-
ties of the different levels of government and the different

55
organizations involved at each level must be clearly speci-
fied, and appropriate intersectoral links must be created.
Beyond that, it is hoped that the Conference and its follow-
up will facilitate exchange on how the problems inherent in
each type of structure can be overcome, so that countries can
adopt economical and effective mechanisms that can re-
spond to the complex and rapidly evolving environmental
health issues of the day.

Reducing risks to health

As the issues involved in managing environmental health are

diverse, control measures must cover a wide spectrum.
Sound legislation and adequate means to implement it are
indispensable prerequisites for control mechanisms. Scien-
tific control limits are often necessary, either as legally
enforceable standards or as guidelines. They may be devised
as appropriate to fit the requirements of individual licences,
such as for discharging an industrial effluent into a river, or
have a more general application such as in relation to a food
additive.
In many instances, land-use planning is important in
optimally siting and controlling new developments that may
adversely affect health and wellbeing. Policy decisions, for
example on methods of agriculture or strategies for energy
production, should fully consider environmental health.
The principle of sustainable development demands new
control strategies that provide strong incentives towards
conservation and health protection. Interest is growing in
extending the principle that the polluter must pay to en-
compass pricing mechanisms, and such tools as tradable
permits may be increasingly used.

56
 All such means should be applied not only to controlling
potential hazards but to striving towards the optimal en-
vironmental conditions conducive to health and wellbeing.

Methods of prevention
Potential hazards to health and wellbeing caused by environ-
mental conditions should be anticipated and prevented,
where possible. The adoption of procedures to assess en-
vironmental health impact and to screen chemicals and con-
sumer products is important for this process. In some
instances, potential risks to health and wellbeing may justify
banning particular activities or products.
Accidents in the home or [Link], on roads and else-
where can be prevented by using appropriate design and
technology and by promoting awareness.
Pollution can be prevented by selecting optimal raw
materials and production processes and by adopting pro-
cedures to recycle and reuse wastes and to use by-products.
Containing pollutants rather than dispersing them into the
environment is appropriate in some cases.
When community development is being planned, at-
tention to such environmental health considerations as noise,
pollution from traffic and the suitability of design and
construction of dwellings and other buildings can prevent
serious subsequent problems.
A comprehensive strategy for prevention requires ap-
propriate incentives, technologies and legislative and ad-
ministrative mechanisms, and that awareness of the import-
ance of prevention be promulgated throughout all sections of
the community.

57
Low-impact strategies

The use of low-impact technologies as part of an overall

preventive strategy for protecting health has been referred to
previously. They are important for efforts to conserve
natural resources and are compatible with sustainable devel-
opment and protecting the environment and human health.

Low-impact technologies are of particular importance in

the fields of energy, transport, industry and agriculture. The
efficiency and effectiveness of the low-impact alternatives
to existing technologies and practices inevitably influence
whether and how they are adopted.

Operational management

Adequately staffed systems of regulation, inspection and

enforcement are as important as appropriate regulations.
Nevertheless, enforcement is only the last line of defence:
sound management is the main rampart. Good, careful,
honest practice is needed at every stage in producing and
disposing of substances and in the use of potentially haz-
ardous technologies. Deliberate evasion of regulations,
careless management and inadequate maintenance often
create hazards to human health.

A key requirement is that every organization and every-

body working in it must accept responsibility for public
safety. It is psychologically difficult to maintain a high level
of preparedness for rare events. New approaches to all
levels of training are required to create the attitudes ne-
cessary to achieve safety in a modem technological society.

58
Regulations

Effectively limiting human exposure to hazardous agents

requires detailed knowledge of their sources and environ-
mental pathways.
It is usually more difficult and costly to remove sub-
stances that have already dispersed into the environment
than to control their production and release. The problems
with nitrate could have been reduced by different fiscal
policies on nitrogenous fertilizers. The cost and complexity
of removing nitrates from drinking-water supplies and from
wastewater will severely burden European countries, and
the lessons learned from this should now be applied urgently
to other issues. Regulations should therefore be applied at
the most appropriate point in the pathway of a hazardous
substance or agent.
Recent WHO surveys of environmental health services in
Europe have shown that legislation is sometimes frag-
mented, with gaps and overlaps in the responsibilities of
particular government agencies. Laws and regulations
should be comprehensive and consolidated, facilitating the
best possible solution to problems at the most appropriate
point in the chain leading from production through environ-
mental release to human exposure. Laws and regulations
should be enforceable and adequate resources should be
available to enforce them.

Standards

Several types of scientific standard are used to protect health

from environmental hazards, including emission standards
(for air and water), product standards (for drinking-water,

59
food and consumer goods) and standards of construction and
design (for housing, motor vehicles, etc.). Great care must
be taken to ensure that they are appropriate and based
on the best available information. H standards are perceived
as irrelevant or unattainable, or if there are no adequate
means to enforce them, introducing them is likely to be
counterproductive.
The nature of a hazard determines whether strict compli-
ance with a standard is necessary. It is inappropriate, for
example, to use the same approach to enforce compliance
with standards for lead and for nitrate in drinking-water.
Based on sound scientific evidence, the acceptable limits for
lead have been progressively lowered over the years; for
nitrate, on the other hand, there are no firm grounds for
thinking that very strict controls are needed to protect human
health. In some cases, guidelines for action might more
appropriately replace standards.
Standards are developed by identifying hazards, estimat-
ing and evaluating risk, and imposing control limits. The
latter part of the process is not purely scientific, but involves
value judgements about cost-effectiveness, practicability
and other factors. The objective of the standard must be to
protect health, but it must be accepted that, in all European
countries, the minimization of risk has at present a very
different order of magnitude when applied, for example, to
reducing road traffic accidents as compared to controlling
chemicals.

Strategies for chemical safety

Considerable progress has been achieved in controlling

potentially toxic chemicals at the national level and through

60
international collaboration among, for example, the Inter-
national Progranune on Chemical Safety, the Com-
mision of the European Communities, the Council for
Mutual Economic Assistance and the Organisation for Econ-
omic Co-operation and Development.
Comprehensive strategies must include testing chemicals
to determine their potential hannfulness to the environment
and health, and implementing appropriate control pro-
cedures. Knowledge is therefore required of estimated
production, distribution and use, and of the processes of
transfer through the environment, transformation and bio-
accumulation. Appropriate monitoring procedures must be
established, sometimes including human exposure and
relevant epidemiological studies. Rational control strat-
egies to protect health and the environment can be applied
only when the relative importance of the various routes of
exposure, including air, water, food and skin contact, have
been established.
Laws, regulations and administrative provisions may
embody scientific limits and controls on, for example, classi-
fication, packaging, labelling, and the use and disposal of
potentially harmful substances. The regulating process may
lead to action ranging from total prohibition, or prohibiting
certain uses or procedures, to use without restriction.
As substantial quantities of chemicals are traded interna-
tionally, testing and control need to be harmonized. The
various economic groups of countries within the European
Region have each progressed considerably in developing
guidelines for toxicology testing for new chemicals and
implementing them as a pre-marketing requirement. Euro-
pean countries have some registration procedures for new

61
chemicals. Many but not all of them are consistent with one
another, and further steps should be taken towards pan-
European harmonization.
Systematically examining existing chemicals involves an
enormous backlog of tens of thousands of substances.
Several attempts have already been made to set priorities ra-
tionally at the national and international levels. Limited re-
sources should be used optimally, so that reliable data can be
generated and disseminated as quickly as possible.

Contingency planning for accidents

Sudden, unforeseen occurrences in the home, at the

workplace, on a highway or elsewhere cause many deaths
and injuries. Accidents constitute the third most common
cause of death in the WHO European Region, after cancer
and cardiovascular diseases. Although the number of acci-
dental deaths and injuries has decreased in recent years, the
relative importance of accidents as a cause of death and
injury is growing, especially among children, young people
and the elderly.
Motor vehicle accidents still account for approximately
40% of accidental deaths, although traffic fatalities have
decreased in most European countries over the last decade.
For every death in a road accident, about 15 people are
severely injured and 30 slightly injured. Injuries require
complex and costly treatment technology, and medical and
social services to care for the disabled.
Accidents in the home account for approximately 40% of
accidental deaths, but affect children and old people dis-
proportionately.

62
 Mortality from work-related accidents can vary by more
than five times from one country to another. Some countries
have substantially reduced deaths over the past few years,
but reductions in the frequency of accidents have been much
less general. Self-employed people and workers on farms
and construction sites and in small manufacturing plants and
workshops are most at risk.
The number of large-scale technological accidents caus-
ing death or injury to the public in recent years in Europe has
been small, except for road, rail, air and sea transport.
Nevertheless, several chemical and radiological catas-
trophes have had widespread consequences, sometimes
across national borders, and have heightened public fears
about the safety of various types of industry, especially
nuclear installations and processing plants for chemical
waste. Perhaps influenced by press coverage, people are
disproportionately concerned about the danger of such acci-
dents and their effects on health, compared to the much
larger risk of accidents at home, at the workplace or
on the roads.
It is sometimes forgotten that several countries of the
WHO European Region, in common with other parts of the
world, periodically experience serious natural disasters in-
cluding earthquakes and floods. These can kill and injure
very large numbers of people, destroy houses, and greatly
disrupt water and sanitation services.
To reduce the frequency and effects of accidents inter-
sectoral efforts are needed, including better standards for the
design and construction of buildings, roads, vehicles, equip-
ment and machinery, high standards of operation and main-
tenance and, most importantly, proper training and infor-
mation for all sections of the community.

63
 Natural disasters such as earthquakes or volcanic erup-
tions cannot be prevented, but their effects on life and health
can be reduced substantially by carefully locating communi-
ties and industrial installations and by appropriate design
and construction of buildings and other structures. The
severity and effects of floods can be mitigated by effective
river-basin and land-use management.
Large-scale natural or technological disasters may ad-
versely affect health in more than one country, which neces-
sitates careful pre-planning, exchange of information and
mutual support. Some countries need international assist-
ance: the WHO Regional Office for Europe has provided
technical support and information facilities after chemical
and nuclear accidents, food poisoning emergencies and
major earthquakes.

Information systems

Information that allows new problems to be identified and

the success of policies and control measures to be moni-
tored, is essential to effective management of environmental
health programmes. Collating information throughout
Europe would allow the status of and trends in environ-
mental factors and health outcome to be compared for
different communities and would allow policy decisions,
including priority setting, to be taken on an increasingly
rational basis. A European system should also facilitate
research on the role of environmental factors in causing
disease.
Despite the many difficulties associated with information
on the environment and health, an increasing number of
satisfactory databases have been established. Successful

64
studies are also being carried out, especially where exposure
can be determined such as in occupational settings.
Information is grossly inadequate on the extent to which
environmental conditions in Europe are causing ill health.
Important public health problems may not be detected. On
the other hand, some conditions may be less harmful than is
popularly supposed, and costly control measures based on
uncertainty may be unnecessarily stringent.
Conflicts of judgement caused by inadequate information
on the nature and extent of environmental health problems
are politically damaging. For all these reasons it is vital to
seek more, and more relevant, information and to make
better use of what exists.
The huge cost of setting up comprehensive databases
suggests that countries should rely on selective, periodic
data collection undertaken for clearly defmed purposes.
Many current environmental monitoring programmes lack
clear objectives and do not provide data suitable for
decision-making. Furthermore, many such programmes are
ineffectively coordinated, for example in relation to the
various routes of exposure.
Despite these limitations and difficulties, more useful
systems of data collection should be developed that permit
selective geographical comparisons of actual exposure to
specific pollutants, and the monitoring of trends. A coherent
European basis for collecting, analysing and interpreting
environmental health data could be of considerable value.

Impact assessment
Environmental impact assessment is now becoming gen-
erally accepted as an important tool in planning new

65
developments. The potential effects on human health must
be fully taken into account in such work and, for this
purpose, appropriate training must be given to health pro-
fessionals and to other disciplines involved in the process.
To have optimal pmctical value, the reports of such assess-
ments should contain appropriate recommendations for fol-
low-up studies during construction, opemtion and, where
applicable, shut-down. These might include monitoring and
epidemiological studies, and the results should be used in
decision-making on a continuing basis.

Experience in several countries has clearly shown the

value of involving local individuals and communities in
planning new development. Such consultations should be an
integral component of the process of environmental assess-
ment, including its health-related components.

The Role of Various Disciplines

in Research and Management

Environmental health research and management both re-

quire multidisciplinary approaches. In most European
countries, health professionals have been inadequately
involved in environmental management, and decisions in-
volving human health may sometimes be taken without their
involvement.

The development of environmental epidemiology has

been understandably slow; studies often involve very small
increases in the incidence of health effects compared to the
variability that may be expected for other reasons. Never-
theless, there have been several successful studies, both in

66
small areas and on a multicentre or multicountry basis. The
necessary measures must be provided to motivate appropri-
ately skilled personnel to work in this field, so that existing
efforts can be augmented. Such work is likely to have
increasing value in achieving a better understanding of the
relationships between environmental conditions and health
effects, and in improving the basis for rational decision-
making.

Progress in these matters is constrained by several impor-

tant factors. In general, medical research organizations and
health services give rather low priority to environmental
health research. The intersectoral and multidisciplinary
nature of the subject sometimes makes it difficult to per-
suade any organization or group to take responsibility for
funding and managing it. Moreover, environmental health
issues often acquire political priority at very short notice,
and efforts by national and international bodies to assign
logical priorities and predict the issues that are likely to
become practically and politically important have so far not
been very successful.

Environmental Epidemiology

Further research is needed to determine or to estimate more

precisely the hannful potential of many environmental fac-
tors and to discover the reasons for the substantial geo-
graphical variation in the incidence of disease. At present,
readily obtainable data meet only a small part of the need, as
mentioned above. Health statistics on small areas are par-
ticularly important in investigating clusters of disease and
possible links with environmental conditions.

67
 In some cases, to cover a sufficiently large population, it
is advantageous to carry out multicentre, multicountry epi-
demiological studies. The International Agency for Research
on Cancer in Lyon, in cooperation with the Regional Office,
carried out such a large-scale study on the health effects on
workers involved in the manufacture and use of man-made
mineral fibres. The Regional Office is coordinating several
multicentre epidemiological studies at present, including
one on how cadmium affects renal function. A similar study
on how low levels of lead exposure influence the intelli-
gence of children was recently completed. In such cases the
effectiveness of the research can be improved by achieving
agreement on common protocols, and by sharing experience
among the various centres involved as the study proceeds.

Epidemiological Surveillance
Health authorities can significantly contribute to the inter-
sectoral management of environmental health through epi-
demiological surveillance, as discussed in the previous two
sections. Such work requires close collaboration at the
local, regional, national and international levels.
The duty to provide relevant information to other sectors
of society and to the general public should be integral to such
work, so as to improve the understanding of health status and
of trends in environmental conditions and to establish more
rational priorities for further action.

Training
Every element of environmental health - water supply
and sanitation, pollution control, water disposal, radiation

68
protection, food and chemical safety, occupational health,
and the public health aspects of urban development and
housing - involves a range of specialized professionals and
auxiliary staff. The most relevant subjects for basic training
are biochemistry, biology, chemistry, engineering and medi-
cine, together with economics and law.
Several European countries have specially trained en-
vironmental health officers who do much of the inspection,
sampling and enforcement and give technical advice, par-
ticularly in local areas. Although competent, well trained
experts in particular fields are needed, overspecialization
is a constant threat. The broad tradition of public health,
which allows problems to be placed in perspective and in-
corporates a due sense of proportion, tends to be forgotten.
The entire spectrum of subjects covered by the Charter needs
to be taken into account, particularly in terms of assessment
and in the allocation of resources.
Expertise should not be disproportionately concentrated
in health and environmental administrations. Industry and
other sectors liable to cause health hazards should also have
trained, authoritative staff whose role is to ensure that
environmental health is taken fully into account in research,
development and management.
The Charter emphasizes that many issues can be most
effectively dealt with by policy-makers and at the earliest
stages of planning. For example, in developing alternative
strategies for energy, transportation or agriculture, properly
trained and experienced staff must be employed at a high
level to achieve the necessary impact on decision-making.
Many professions and occupations increasingly need
people who have had some training in environmental health,

69
even though their work does not specifically focus on en-
vironmental health. As a minimum, they should understand
the types of hazard that may arise in their work and the
importance of foresight and continuing vigilance. The train-
ing should cover not only their own health and safety but
also the possible effects of their work on others, including
the general public.
In such a wide and rapidly changing field skills clearly
need to be kept up to date, implying that refresher training is
essential throughout the working life.
Education for both young people and adults must pro-
mote greater understanding of the nature and relative magni-
tude of the various environmental health hazards people may
encounter, focusing on local conditions that people ex-
perience every day.

70
Priorities
Although it is important to move towards the principles of
the Charter, many pressing issues need to be dealt with
immediately.
The environmental health problems facing different
countries and different local areas, the degree of potential
harm, the costs of remedial action and the resources avail-
able all vary enormously. Priorities cannot be uniform across
Europe but should be established locally, nationally and
internationally, according to the topic.
These priorities should take into account both the extent
of risk to the people most affected and the number of people
affected: that is to say, the risk to the individual and to the
community as a whole. The likelihood of harm should be
balanced against its severity should it occur. A very low
probability that an event will occur may be acceptable
if few people can be harmed, whereas it is not acceptable if
many people are at risk.
The scientific basis for environmental health policies and
programmes is evolving rapidly but has important limit-
ations. Conclusive evidence on environmental health issues
is sometimes very difficult to obtain, particularly for chronic,
long-term effects, although these may be the most important.
Determining the correct priorities therefore requires careful

71
and expert assessment of the full body of evidence available
on each topic. Numerous hypotheses are being considered at
any one time. Many of them fail to survive adequate testing,
and very preliminary ideas may be given too much weight.
Further, interpreting the evidence is often extremely diffi-
cult, such as in the case of short-term carcinogenicity tests,
and ill-founded interpretations do get published. For many
decades to come decisions will have to be taken on uncertain
and incomplete evidence, but policy-makers should at least
benefit from the best available advice.

Priorities of Special Concern

The Charter states that the governments and other public

authorities of the European Region, without prejudice
to the importance of problems specific to their respective
countries, should focus particularly on the following ur-
gent issues at the local, regional, national and international
levels.

Global disturbances to the environment

Several consequences for health of air pollution are of global

concern. Chlorofluorocarbons, widely used in refrigerators,
aerosols and elsewhere, have depleted the stratospheric
ozone layer to such an extent that worldwide efforts are
being made to phase them out. The consequences for skin
cancer and cataracts are difficult to predict, but one estimate
suggests that a 1% decrease in the stratospheric ozone
concentration will lead to an 8% increase in skin cancers in
fair-skinned people. A depletion of 3% in the temperate
zones of the northern hemisphere has been postulated: this

72
would lead to 80 000 new cases of skin cancer annually in
the United States, corresponding to approximately 250 000
in the European Region of WHO. An important gap in
knowledge is the effect of increased ultraviolet radiation on
other animals and on plants such as phytoplankton, and the
subsequent indirect effects of this on human health.
Chlorofluorocarbons also contribute to global warming -
the so-called "greenhouse effect", which is mainly caused
by the increasing concentration of carbon dioxide, methane
and nitrogen oxides in the atmosphere. Recent estimates
suggest that the mean global temperature will increase by
1.5-4.0 °C over the next 50 years.
Past emissions will continue to affect atmospheric levels
of carbon dioxide for several decades. It is too soon to know
whether such targets as a 20% reduction of the present
carbon dioxide emission levels by the year 2005 are realistic
and likely to be achieved, but reliable estimates of tem-
perature change are needed covering best- and worst-case
assumptions for atmospheric carbon dioxide levels. Only
when this information is available can meaningful attempts
be made to assess the extent of associated changes in sea
level and rainfall, or in fresh water and coastal ecosystems
(including the effects of climatic change on the life cycles of
pests and plant diseases and on natural vegetation). The
greenhouse effect may also more directly affect human
health by, for example, changing the prevalence of tropi-
cal diseases, affecting the toxicity of pollutants, causing
flooding in heavily populated coastal areas, and reducing
supplies of fresh water as a result of seawater incursion.
The likely scale of these effects on the environment and
human health must be better understood before priorities can

73
be set and countermeasures planned. Interdisciplinary re-
search will become increasingly important as we resolve
present uncertainties as to how best to prevent the green-
house effect from progressing further and, if possible, re-
verse it.
Despite energy-saving policies, the European countries
are likely to need more than 25% more electrical
generating capacity in the next 25 years. The health impli-
cations of alternative energy strategies therefore need care-
ful consideration.

Urban development, planning and renewal

The quality of the built environment substantially influences
people's lives. Besides the adverse health effects of pollu-
tion, there is also increasing evidence of the stressful effects
of noise, dirt and congestion on mental health and behaviour.
The communities participating in the WHO Healthy Cities
project have demonstrated the benefits of intersectoral
action backed by strong political commitment and active
public participation.
Recent studies have identified the environmental prob-
lems that take priority in European cities as air pollution,
noise, solid wastes and litter, pollution of urban water-
courses, lack of green spaces, the low aesthetic quality of
many new buildings, and the rapid decay of much housing
constructed during the last 30 years. These issues are
usually better approached as part of a broad urban policy
than in isolation. For example, enlightened urban transport
planners take into account air pollution, noise and the need
to protect urban green areas from road development. An-
other example is that preventing illegal parking makes it
easier to clean the streets.

74
 Rehabilitating unsatisfactory conditions often depends
less on legal power and enforcement - necessary though
these are - than on encouraging civic interest and pride,
including asking more of people and less of equipment and
technology. This approach can improve the public's attitude
towards reducing noise and towards using facilities to col-
lect and recycle litter and garbage. Public interest and
response are more likely to be awakened by making a
concerted and well understood effort to improve the urban
environment than by concentrating on a single issue.
Many of the detailed issues in urban areas are covered
under subsequent items, but they should still be considered,
as far as possible, in the context of healthy cities and
communities.

Safe and adequate drinking-water supplies

and hygienic waste disposal

Safe water and sanitation are essential to human health.

Water-related diseases are still an important problem in
some parts of Europe.
In the European Region as a whole, with a population of
some 840 million, an estimated 70 million people have no
piped water in the home. There is no accurate estimate of
how many people have microbiologically unsafe drinking-
water; 50 million is probably an understatement, and the
data on sanitation are even less complete. In urban areas
alone, about 30 million people are not connected to public
sewerage systems. More than half of the wastes collected
through sewers are discharged untreated.
For public health, the highest priority must be to provide
the entire population with adequate and reliable supplies of

75
microbiologically safe water. The presence of hannful
chemicals, however, is an increasingly important problem.
As a single water source can supply several million con-
sumers, generous safety factors must be applied. Water
supplies are contaminated by both point and non-point pol-
lution sources. The latter, including agricultural activities,
especially affects groundwater aquifers.

Under some circumstances, the only way to protect health

is to ban or control the production or specific uses of
potentially hannful chemicals. One governmental agency
normally cannot justify or accomplish such measures; they
require an intersectoral approach involving government
bodies, industry and commerce. If trade considerations and
perhaps shared water resources are at stake, several coun-
tries may need to act together. Interventions should be made
at the optimal point in the environmental pathway, not
necessarily at the water-treatment plant.

The 1984 WHO Guidelines for drinking-water quality,

now being revised, give a detailed rationale and guideline
levels for biological, chemical and physical contaminants.
General compliance with these guidelines would provide
significant health protection to the population of the WHO
European Region.

The Regional Office's recent survey on water services in

Europe shows that, in some cases, a wide variety of
ministries are involved and to a varying degree central,
provincial and local government bodies, perhaps poorly co-
ordinated. The available data and information are some-
times unsuitable for assessing health or for making decisions
on policy, programmes or projects. The number and com-
plexity of issues of water supply and pollution control now

76
confronting European countries generally require greater
national, provincial and local emphasis on the public health
dimension.

Water quality

In many countries of the WHO European Region, gross

pollution of rivers and lakes has diminished during the last
20 years. In a smaller number of countries, the situation still
appears to be deteriorating because the rapid progress of
industrialization and increasing demand for water have not
been accompanied by enough investment in measures to
safeguard water quality.
In all countries, the proliferation of chemicals in the
environment has increased problems of potentially toxic
micropollutants in the aquatic environment, some arising
from non-point sources. Land-use decisions may signifi-
cantly affect the quality of surface water and groundwater:
many problems result from changes in agricultural and
forestry practices. Such contaminants as heavy metals and
man-made organic substances in rain and snow can markedly
pollute surface water and groundwater. Acid deposition,
responsible for serious damage to lakes and forests, may
indirectly affect human health.
Some trace contaminants may not directly harm human
health but may pass through a complex system of environ-
mental pathways and bioaccumulation and thereafter in-
crease human exposure significantly. Using contaminated
water for irrigation and thus progressively increasing con-
taminant concentrations through recycling can pose health
problems.

77
 Some of the most important rivers in Europe such as the
Danube and the Rhine flow through several countries, and
many smaller rivers and streams flow across national frontiers
or form their boundaries. Besides the continuous discharge
of polluted wastewater, accidents result in sporadic pollu-
tion, some of which worsens the quality at public supply
intakes several hundred kilometres downstream.
Public pressure and a greater awareness of the finite
capacity of coastal waters, especially enclosed seas, have led
to many successful pollution control programmes during the
last few decades. Nevertheless, many stretches of European
coastal water are polluted and, all too often, the increasing
numbers of tourists encounter many bathing beaches and
marinas that are heavily contaminated with sewage from
nearby outfalls. Shellfish are susceptible to both micro-
biological and chemical contamination, and edible fish may
be poisoned or have their flesh tainted by pollution.
Appropriate action to prevent and control water pollution
may include stopping individual sources, but also im-
plementing land-use policies that consider fully water
quality. In some instances, broad policy decisions may be
appropriate at a national or international level: for example,
fiscal measures to control nitrate pollution of arable land.
Many of the environmental health dimensions of water
pollution control require close international collaboration,
including transfrontier issues and preparing codes of prac-
tice on such matters as controlling groundwater quality and
protecting recreational waters.
Microbiological and chemical safety of food
All recent indications show that foodbome diseases are
increasing markedly. In one country the number of recorded

78
cases has tripled in six years, yet even in countries with good
reporting systems it is estimated that only 1-10% of food
poisoning cases are reported. Poor food safety and sanitary
measures cause most foodborne infections, poisonings and
outbreaks of diarrhoea! diseases.
One example has been the rapid increase in the preva-
lence of Salmonella enteritidis, which can infect the ovi-
ducts of poultry and thus pass into the eggs, affecting both
consumers and the next generation of birds.
The nature of the relationship between the presence of
Listeria monocytogenes in food and clinical cases of human
listeriosis is still uncertain. Nevertheless, the vulnerability
of pregnant women to listeriosis and the associated risk of
miscarriage or stillbirth make the presence of L. mono-
cytogenes in certain foods a cause for concern. As incidents
have clearly occurred in a number of European countries,
improved international exchange of information on in-
cidence, epidemiology and means of prevention and control
is needed.
These and other examples of microbiological food in-
fection have seriously hurt public confidence in the safety of
many foodstuffs. In this situation, many of the Charter's
principles are important, including predicting the effects
of new methods of food production, processing and storage,
achieving high standards of management, and strongly
emphasizing basic hygiene and adherence to codes of good
practice.
The WHO Regional Office for Europe recently published
a second edition of its book Food safety services. 0 In

a Food safety services, 2nd ed. Copenhagen, WHO Regional

Office for Europe, 1988 (Public Health in Europe No. 28).

79
many European countries, food control services are divided
among different authorities. Sometimes responsibilities are
not clearly defined, and coordination between central and
local authorities appears to be lacking. Although legis-
lation is usually adequate, some countries lack systematic
implementation in the form of routine surveillance and
control by well trained and strongly motivated personnel.
The basic information and data on foodbome diseases
and other relevant factors are inadequate and incom-
plete for Europe as a whole, and often for countries and local
communities as well.

Food and people increasingly move across national bor-

ders, which means that the problems cannot be solved en-
tirely within each country. Tourists appear to be particularly
at risk: a recent estimate suggests that more than 40% of
international holidaymakers suffer from diarrhoea. The
proposed changes in trade regulations for the 12 countries of
the European Communities for 1992 will pose significant
challenges for food safety throughout Europe. It is not clear
that these challenges are being taken up with sufficient
urgency, given the short time frame involved.

Although great efforts have been made to control po-

tentially harmful food additives, at both national and inter-
national levels, the situation becomes more complex. In
some countries, for example, mayonnaise may have more
than 40 legally permitted additives. Several serious cases of
fraudulent chemical contamination of food have involved
large numbers of consumers in Europe during recent years.
The toxic oil syndrome in Spain, for example, resulted in the
death of over 500 people and serious impairment of health in
a further 20 000.

80
Environmental and health impact
of various energy options

Consciousness is growing of hazards to health and the

environment at different stages of the fuel cycle, and greater
efforts are therefore being made to develop low-impact
technologies such as solar and wind power, and to use
sustainable biomass. Hydroelectric power has almost
reached its limit in many European countries, although tidal
power still offers some possibilities for growth. Some of
these technologies are likely to be increasingly useful in
Europe under the right conditions, but for the foreseeable
future Europe's high demand for energy will need to be met
largely by burning fossil fuels and by nuclear power.
The risks to exploiting coal and oil are apparently greater
than to those producing nuclear power. The consequences of
fossil fuels for the environment and health are associated
mainly with production and combustion, either in stationary
sources or motor vehicles, whereas for nuclear power they
are related to accidents, decommissioning of plants and dis-
posing of radioactive waste. The potential risks of nuclear
power therefore have a higher profile and are more dramatic,
a fact which significantly affects public opinion.
At present, energy policies and projections of energy
supply, demand and economics do not take sufficient ac-
count of environmental health. Yet public pressure is in-
creasingly delaying, substantially modifying or causing the
abandonment of planned developments. A more systematic
study of the effects on health of alternative energy strategies
is urgently needed.
Energy conservation has a large and immediate potential,
with significant consequences for health. Policy decisions

81
are required in a number of other sectors including transport,
industry and housing; the full health impact of these de-
cisions needs to be reviewed.

Environmental and health impact

of road transport

Private automobile ownership is growing rapidly in almost

all European countries, and the proportion of goods moved
by road over both long and short distances is increasing. The
modem road vehicle is safer and quieter, consumes less fuel
and pollutes less than its predecessor of even a few years
ago, but the growing density of traffic and the infrastructure
necessary to support it are profoundly affecting both urban
and rural areas. The great benefits of road transport in
convenience and flexibility must be weighed against the
environmental and health problems it causes.
Despite better design and more stringent controls, vehicle
emissions are responsible for a substantial proportion of air
pollution. Near busy city streets, often in dense residential
areas, toxic materials in the air such as carbon monoxide,
nitrous oxides, lead, formaldehyde, benzene, pyrene and
soot frequently exceed acceptable levels. In some countries,
heavy diesel-powered vehicles are poorly maintained, lead-
ing to unnecessarily high emissions of noxious exhaust
fumes.
In many European cities, traffic emissions are the main
cause of photochemical smog. The many deaths and wide-
spread distress that occurred during two successive
summers in one town in southern Europe have been at-
tributed to a combination of dense traffic pollution and
high temperatures.

82
 Traffic noise, especially from heavy diesel-powered
vehicles and motorcycles with low engine capacity, is in-
creasing in both cities and rural areas. It causes significant
stress and is a major reason why people are dissatisfied with
their surroundings. Noise is also still a problem near many
airports, even though much quieter aircraft engines have
been introduced.
In some cases urban traffic congestion has increased
journey times to more than what they were 100 years ago.
The vast number of private cars used and parked in city
centres causes congestion and stress. Parked vehicles often
prevent pedestrians from using the pavement and prevent the
streets from being cleaned properly.
Intersectoral action is urgently needed throughout Europe
to develop and implement healthier transport policies.

Environmental and health impact

of agricultural practices

Agricultural production in Europe has increased greatly in

the last 50 years. The ploughing of grassland and heavy use
of chemicals on arable land have led to difficult problems
with water quality, including increases in nitrate concentra-
tions and the presence of potentially harmful pesticides in
drinking-water. Levels of nutrients in many inland and
coastal waters are much higher than they were a few decades
ago, largely because of a 10- to 20-fold increase in the use of
nitrogenous fertilizers.
Much animal production is now concentrated in in-
tensive units. Cross-contamination by Salmonella and other
organisms is an increasing problem. In addition, waste

83
disposal has created serious air and water pollution prob-
lems, including the production of large concentrations of
ammonia and methane and the presence of additives, which
prevent solid wastes from being used as fertilizer. Additives
to animal feed, including antibiotics and anabolic steroids,
are an increasing concern for public health.
Seepage from silage has extensively polluted surface
waters and groundwaters used for public drinking-water.
Sewage sludge from waste treatment plants - sometimes
still untreated - is used in some areas for fertilizing leaf
vegetables, which may then be eaten raw.
Agricultural production is now substantially industri-
alized, yet farms are often exempt from many of the planning
controls and other safeguards that apply to industry and
commerce.
In accordance with the principles of the Charter, the
implications for environmental health of agricultural
practices should now be examined more closely and
comprehensively.

Air quality

Lung function is affected by many pollutants, and toxic

agents in air have both acute and chronic effects,
including carcinogenicity and mutagenicity. Even minute
concentrations of some contaminants can cause distress
because they affect sensory organs.
More effective controls have considerably reduced both
domestic and industrial emissions throughout most of
Europe. In some heavily industrialized areas, however, air
pollution, especially from metal smelting plants, poses a

84
serious direct threat to health. Surface deposition and uptake
by crops have also contributed to these risks in some areas.
The increasingly dense European road traffic emits grow-
ing amounts of exhaust, despite the progressive introduction
of more stringent controls. Even well maintained diesel
engines emit particulates that may harm the respiratory tract
and potentially carcinogenic hydrocarbons.
The deposition of air pollutants on soil or bodies of water
can also indirectly affect public health, as chemicals enter
the food chain or reach drinking-water.
Sulfur dioxide, one of the main air pollutants, is haz-
ardous to both the environment and health. Its main source
is the combustion of fossil fuels. Besides its indirect effects
through environmental contamination, it directly affects the
respiratory tract and lungs at moderate levels of exposure.
Emissions from small domestic, commercial and industrial
premises have tended to decline in recent years, but
emissions have increased dramatically from large power
stations, which disperse pollutants at high altitudes. Suc-
cessful international efforts are reducing overall emissions,
and particularly transfrontier acid deposition.
In many parts of Europe, urban levels of sulfur dioxide
and particulates are much lower than they were a few
decades ago, but in some areas the combustion of low-grade
brown coal still causes heavy pollution. Heavy smogs can
occur, especially during windless conditions and climatic
inversions, resulting in considerable excess mortality and
morbidity and widespread discomfort.
Further reductions of sulfur dioxide emissions require
better technology or changes in the policies for energy
production and use.

85
 Nitrogen dioxide is a product of fossil fuel combustion in
both stationary sources and motor vehicles; levels are still
increasing in many areas of Europe, especially in towns. It
directly affects lung function and its presence in the at-
mosphere can produce ozone and other photochemical oxi-
dants. Ozone, at its present concentrations in many heavily
populated areas in Europe, can cause ear, nose and throat ir-
ritation, headaches and damage to lung function. It can also
lead to unpleasant photochemical smog.
Reducing nitrogen dioxide emissions requires more strin-
gent controls and modified energy and transport policies.
In 1987, the Regional Office published its Air quality
guidelines for Europe, 0 which established guideline concen-
trations in air, based on scientific criteria, for 28 pollutants
or groups of pollutants that threaten health. General compli-
ance with these guidelines would greatly protect the Euro-
pean population from both the direct and indirect effects of
air pollution.

Indoor air quality

Most Europeans spend less than 20% of their time in the
open air. This demonstrates the importance of air quality in
buildings and other enclosed spaces, such as motor vehicles,
trains and aircraft. The concentrations of nitrogen dioxide,
carbon monoxide and other pollutants in buildings may
exceed outdoor levels. New construction methods and new

a Air quality guidelines for Europe. Copenhagen, WHO Regional

Office for Europe, 1987 (WHO Regional Publications, European
Series, No. 23).

86
materials for furniture and fittings, together with more effec-
tive thermal insulation, have increased the risks to health of
potentially harmful contaminants in the indoor environment.
The term "sick building syndrome" has been applied to
blocks of flats, hospitals, offices and schools constructed
mainly during the last 25 years, where occupants have
experienced sickness and discomfort. The phenomenon can
seldom be attributed to a single factor, but the distress
caused has forced the closure of many such buildings so that
improvements could be carried out. In extreme cases,
buildings only a few years old have been demolished.
In larger buildings, central heating and air conditioning
systems can rapidly spread biological and chemical con-
taminants. Legionellosis has been associated with such sys-
tems and has spread quickly in Europe over the last few
years.
Tobacco is a significant indoor air pollutant, and firm
evidence indicates that exposure to other people's tobacco
smoke increases the risk of cancer.
In some areas of Europe, significant concentrations of
radon seep into buildings from the ground, and some
building materials also release radon. Systematic monitor-
ing has only recently been carried out, and only in limited
areas. Radon is recognized to be second only to tobacco
smoking as a causal factor for lung cancer: 5-15% of lung
cancers are attributable to exposure to indoor radon.
There now has to be a better understanding of the factors
influencing health in relation to indoor climate and air
quality, embodied in codes for building design, construction
and product safety. In many countries, responsibility for
these issues is fragmented both centrally and locally.

87
Persistent chemicals and
those causing chronic effects

People may be exposed to potentially hazardous chemicals

when they are produced, distributed, used or finally dis-
posed of. Approximately 60 000 chemicals have been
marketed in Europe, and not all have been stringently tested
for their effects on health and the environment. Some persist
in the environment and some can cause chronic effects on
health, including carcinogenicity and neurotoxicity. Most
risk assessments require extrapolation from short-term,
high-dose animal experiments to predict long-term, low-
dose effects in humans; epidemiological studies are difficult,
costly and time consuming. In some cases, complex path-
ways are involved that include air, water, soil and the biota.
The public is very cautious in accepting the safety of
chemicals in air, water and food, although in many cases
considerable proof of safety is available. A number of
highly publicized accidents have especially shaken public
confidence. The idea is growing in some countries that
chemicals have been marketed without a proper balance
being struck between their advantages and usefulness to
society and their possible risks to health.
There have been substantial recent international and
national efforts to control both new and existing chemicals
by assessing their potential harmfulness to health and the
environment. The International Programme on Chemical
Safety, the Joint FAO/WHO Expert Committees on Food
Additives and Pesticide Residues, the International Agency
for Research on Cancer, the Commission of the European
Communities and the Organisation for Economic Co-
operation and Development have been active internationally.

88
A sizeable backlog remains, however, in the toxicological
assessment of single chemicals, and the effects of most
combined exposures to two or more chemicals, or to a
chemical and other harmful agents, are still not well under-
stood. The effects of chemicals on vulnerable groups at the
workplace or in the general population, such as pregnant
women and people who are allergic or genetically sensitive,
demand special attention. Effects of low-level exposures on
the central nervous system and hence, for example, on be-
haviour and intelligence are also as yet not fully understood.

Hazardous wastes
For many years, the dumping of hazardous wastes was
virtually uncontrolled in many European countries. Large
areas of agricultural land had to be abandoned and toxic
materials leached into both surface water and groundwater.
Although restrictions are now becoming more stringent, for
both local disposal and transfer between countries, many
problems remain. The quantity and complexity of newly
generated wastes is still increasing despite conservation
measures. Industry and local authorities have great practical
difficulties in disposing of such wastes in a manner that
protects public health and the environment; neighbourhoods
are often reluctant to accept processing plants for hazardous
waste, including incinerators, because of public doubts
about their safety.
On a smaller scale, facilities are not always available to
collect and dispose of such hazardous consumer products as
waste oil and household and farm chemicals.
In many European countries, no precise information is
available on the location or content of old industrial waste

89
dumps, and public health problems have arisen because
housing and other developments are unknowingly allowed
on such sites. Some residential areas have had to be evacu-
ated because of emissions from industrial wastes that were
buried long before the houses were built. In some areas,
consumption of vegetables has had to be prohibited due to
soil contamination by such wastes.
Although the generation of hazardous wastes in industrial
plants must be minimized and materials must be recycled
and recovered, hazardous wastes will inevitably be a major
problem in Europe for many years. The environmental and
health problems must be addressed: primary prevention,
improved understanding of health risks, the introduction of
safeguards for old dumping sites, and better disposal prac-
tices for wastes produced in future.

Biotechnology

Recombinant DNA technology allows specific genetic in-

formation to be transferred from one cell to another. This has
led to the rapid development of processes that have im-
portant practical applications, including the potential ex-
ploitation of a wide range of renewable raw materials for the
food and manufacturing industries, the production of phar-
maceutical products and diagnostic equipment for health
care, the production of alternative fuels, and more efficient
use and disposal of waste materials.
Careful assessment of potential effects on occupational,
environmental and public health must be integral to develop-
ing any practical application of biotechnology. The indus-
trial use and appropriate containment of organisms patho-
genic to higher animals, plants and humans must receive

90
special attention. Moreover, care must be exercised in
deliberately introducing into the outside environment
genetically altered microorganisms or higher organisms that
can survive or multiply there.
Most organisms used in industrial processes are unlikely
to successfully compete with those in the outside environ-
ment or are so disabled that they cannot survive outside the
controlled and favourable environment of the industrial
plant. Nevertheless, organisms that have been deliberately
engineered to grow on natural substrates may have an en-
hanced ability to survive, and must therefore be appropri-
ately contained. Experiments and pilot trials with micro-
organisms intended to be used in the outside environment
should be carried out under confined conditions, to assess
safety and long-term effects. Similarly, experiments on plants
to improve properties for growth by inserting recombinant
DNA should be carried out under confined conditions until
the plant characteristics have been fully evaluated.
Biotechnical processes use large quantities of water, and
waste treatment needs to be carefully considered. Aerosols,
dust and aqueous effluents and sludges may cause health
problems.
All European countries need to develop evaluation and
control strategies, supported by legislation, to allow these
important new techniques to be developed without preju-
dicing the environment and health. Existing international
cooperation should appropriately be extended to include
research, training, the design and evaluation of epidemi-
ological studies, and the development of appropriate guide-
lines based on the work that WHO and other international
organizations have already carried out.

91
Contingency planning
for accidents and disasters
Despite all reasonable efforts to prevent sudden events that
may have serious direct and indirect effects on human
health, accidents will inevitably happen. A European society
that depends increasingly on complex and diverse tech-
nology needs careful and comprehensive contingency plan-
ning and emergency response to mitigate the adverse effects
of technology on both the population and the environment.
Preparedness requires close intersectoral collaboration
locally, nationally and internationally. Many recent emer-
gencies, including pollution of water supplies, food trans-
portation accidents, the transfrontier consequences of nu-
clear and chemical accidents and natural disasters, have
revealed shortcomings in such cooperation.
Reliable information must be collected, collated,
analysed and disseminated. The public must have ready
access to information it can trust. In several recent cases
advice has been fragmented, incomplete and inconsistent,
leading to a serious loss of public confidence and preju-
dicing the success of control and rehabilitation measures.
Since the nuclear accident at Chernoby1 many local,
national and international steps have been taken to improve
contingency planning for any such accident in future, par-
ticularly where the consequences may transcend national
boundaries. Recent expert groups convened by the WHO
Regional Office for Europe have emphasized the diversity of
possible nuclear emergencies, which could involve not
only power stations but reprocessing plants, fixed and
mobile sources of radiation for medical or industrial use,
nuclear-powered ships or space vehicles, and nuclear
material being transported by road, rail, sea or air.
92
 Proper effective intersectoral plans must now be devel-
oped and tested for other types of emergency that could
affect health either directly or indirectly by contaminating
air, water, food or soil or by disrupting vital services. Inter-
nationally, rapid and efficient systems are needed that can
transfer information on how to protect the population and the
environment after an accident, including early warnings and
mechanisms to obtain technical advice and support.

Cleaner technologies

The importance of introducing low-impact technologies has

already been discussed on page 58. The extent to which low-
impact technologies are introduced depends significantly on
the development of appropriate, effective and reliable alterna-
tives to existing technologies and practices and of incentives
that encourage people to adopt them.

Low-impact technologies are important in such fields as

energy, transportation, industry and agriculture. In addition,
such developments as the introduction of returnable or de-
gradable packaging and containers would markedly benefit
the human environment in Europe, since the growing quan-
tities of plastic wrappers and metal drinks cans affects both
urban and rural environments.

lntersectoral Environmental Planning

and Community Management
Earlier sections of the Charter stressed the importance of
securing intersectoral action for many issues related to
environment and health. Whereas many of the objectives

93
pursued by different authorities may appear to be incom-
patible, an open dialogue must continue and the European
Charter should provide a basis for concerted action on
environment and health by all sectors. Such an integrated
approach is essential for all the priorities enumerated in this
section of the Charter.
The community is an appropriate focus for intersectoral
action on many issues; the WHO Healthy Cities project has
already provided some striking examples of this. Partici-
pating communities have demonstrated how enlightened
intersectoral planning and community involvement can safe-
guard health and wellbeing by influencing layout and de-
sign, pollution control, noise abatement, transport facilities
and recreation areas. Health and social problems have arisen
in many European urban development schemes during the
last few decades, largely because health and social workers,
architects and other professionals did not predict the con-
sequences of what was being planned and work together to
develop more appropriate solutions.
Such efforts should not only aim at controlling un-
satisfactory conditions but also, more positively, to create an
environment that generates optimal health and wellbeing for
all sections of the population.

Health Promotion
The 1986 Ottawa Charter for Health Promotion states:
"Health promotion is the process of enabling people to
increase control over, and to improve, their health. To reach
a state of complete physical, mental and social wellbeing, an
individual or group must be able to identify and to realize

94
aspirations, to satisfy needs, and to change or cope with the
environment. Health is, therefore, seen as a resource for
everyday life, not the objective of living''.

Environmental conditions and personal lifestyles, which

mutually interact in many ways, are both important for
human health and wellbeing. People's nutrition and smoking
habits, for example, can amplify the effects of particular
harmful agents, and the physical and social environments in
which people live and work can substantially influence their
lifestyles. Promoting healthier lifestyles, which European
countries increasingly accept as an important component of
health for all strategies, is therefore an essential corollary to
improving and sustaining environmental conditions.

International Cooperation

Many important international initiatives have been taken

in the field of environmental protection. Many United
Nations agencies have environmental programmes, and
mechanisms are in place for regularly exchanging in-
formation and for joint action. Examples of long-term
collaboration are the FAO/WHO Codex Alimentarius Com-
mission and the Joint FAO/WHO Expert Committees on
Food Additives and Pesticide Residues. Another excellent
example is the Mediterranean Action Plan, which has a joint
secretariat in Athens comprising staff members from the
United Nations Environment Programme (UNEP), FAO and
WHO. The International Programme on Chemical Safety,
which is responsible inter alia for the documents on health
criteria for chemical safety, was jointly established by WHO,
the International Labour Organisation (ll..O) and UNEP.

95
 The WHO Regional Office for Europe has carried out
many environmental health activities with the United
Nations Development Programme (UNDP), UNEP, the
Commission of the European Communities (CEC), FAO,
the International Atomic Energy Agency (IAEA), the United
Nations Educational, Scientific and Cultural Organization
(Unesco) and ILO. The Regional Office maintains close
contact with several directorates of CEC, and several joint
activities and projects have been carried out. The Regional
Office has worked closely with OECD on nuclear safety, and
with the Council for Mutual Economic Assistance on inter-
national water resources. The Regional Office also works
closely with the environmental programme of the Council
of Europe.

In respect of all these organizations, there is mutual

participation in expert meetings and a frequent exchange
of information. Nevertheless, the public health aspects of
environmental protection and management do not always
receive adequate attention at the international level, com-
pared with protection of the ecosystem.

Unfortunately, the various aspects of the subject as-

sembled in the Charter have, in the past, not generally been
regarded as a cohesive whole requiring intersectoral atten-
tion and action. Many aspects of this cooperation are in
place, such as elements of chemical safety and pollution
control, but others need considerable strengthening, includ-
ing the establishment of environmental health databases,
health impact assessment and the health dimensions of the
urban environment.

The ramifications for health of global disturbances to the

environment will definitely require further international

96
attention during the next few years. Many of the other
priorities listed in this section of the Charter transcend
national borders and most require international, especially
pan-European, cooperation to be satisfactorily resolved.
Well coordinated joint efforts in research and development
should also facilitate the most effective utilization of avail-
able resources.

97
The way forward

Despite the many improvements achieved throughout the

European Region, some environmental conditions that af-
fect human health are still deteriorating in particular lo-
calities, including pollution from the combustion of low-
grade coal, from metallurgical plants and from increasing
road traffic. International problems, including atmospheric
changes, may have increasing effects in future. Negative
trends must therefore be arrested and reversed; in some
cases, existing programmes may need to be strengthened.
Environmental health improvements already completed or
in progress should be maintained and if necessary aug-
mented, in accordance with the principles and strategies of
the European Charter and WHO regional strategy for health
for all (Annex 1).

International Collaboration
Many environmental health issues facing Europe have an
international dimension, including air and water pollution
across national boundaries and issues related to food trade,
hazardous substances, wastes and consumer products. Even
where problems are perceived as local, collaboration be-
tween governments and with international organizations can
assist in developing effective solutions by using available
98
resources most effectively, by sharing experience, and by
coordinating joint efforts in research and development.
Much bilateral and multilateral collaboration is already
in progress, especially among particular economic group-
ings of countries. The time is now ripe to extend such
initiatives to cooperation throughout Europe. The inter-
country environmental health programme of the WHO
Regional Office for Europe has established a fmn founda-
tion and could be used as a basis for enhanced efforts.
It is proposed that the Charter be translated into all the
languages used in the Region and widely disseminated. It is
further proposed that WHO, in collaboration with other
international organizations, strengthen the international
mechanisms for assessing potential hazards to health from
the environment, bearing in mind the multifaceted and
complex nature of the problems that involve many routes of
exposure and aspects of the environment including the home,
the community and the workplace.
WHO has already drawn up guidelines on air and drink-
ing-water quality and on many other subjects: water supply
and sanitation, pollution control, radiation protection,
chemical and food safety, occupational health, and public
health aspects of housing and settlements. It is proposed that
this work be developed in cooperation with other organiz-
ations to take into account the need for a unifying and
interdependent approach to the multisectoral issues ad-
dressed by the Charter.
In many respects we lack the necessary data and infor-
mation to make decisions on both longer-term and short-
term strategies, including strategies for emergencies. This
problem must be addressed cautiously: any measures taken
must be well coordinated internationally, nationally and

99
locally, and clearly defmed objectives must be established so
that the information gathered is both relevant and practical.
The work already being done by WHO and other inter-
national organizations must be fully taken into account. But
it is not as important which organization carries out a
particular task as to ensure that all aspects of the Charter are
implemented in a manner that reflects their interrelationship
and interdependence. The whole is clearly greater than the
sum of its parts.

Indicators
In 1984 the WHO Regional Committee for Europe endorsed
38 targets for health for all. Evaluation of progress towards
achieving these targets requires proper indicators. Indi-
cators are difficult to design and use for several of the
targets, particularly those for which structures and mech-
anisms are to be established. On specific issues such as
providing water supplies, indicators are more straight-
forward. The validity of existing indicators of environ-
mental effects on health should be evaluated critically.
Furthermore, where such indicators are missing, new indi-
cators that are both specific and valid should be developed
and a database established so that trends and progress can
be measured. This will also help to monitor progress in im-
plementing the Charter.

European Advisory Committee on

the Environment and Health
To ensure that all the Charter's elements are taken into
account in WHO's future work in Europe, and that advice is

100
available for Member States, it is proposed that a Euro-
pean Advisory Committee on the Environment and Health
be established that comprises representatives of Member
States, selected multisectorally, and that meets at least once
a year. This Committee would advise the WHO Regional
Director for Europe on all policy and programme matters,
and review status and trends. From time to time, the
Committee might also wish to review particularly pressing
subjects in depth.

European Centre for

Environment and Health

The Charter emphasizes that the wide-ranging environ-

mental health problems now facing Europe require a multi-
disciplinary and intersectoral approach; many need to be
dealt with internationally. At the invitation of individual
countries, several WHO regional offices have now set up
environmental health centres, each providing an inter-
national setting for a small interdisciplinary core group with
seconded and visiting experts. These centres have pro-
moted, catalysed and coordinated studies and research. They
directly participate in technical cooperation with Member
States and act as clearing-houses for information.

Although the WHO Regional Office for Europe has long

had a substantial programme on environment and health, the
staff must spend substantial time on their day-to-day work;
longer-term objectives need a different setting. For many
years WHO has used networks of collaborating centres,
chosen to cover specific fields and asked to complete spe-
cific tasks in a given time. Environmental health problems

101
are multisectoral, diverse and complex, which has made it
difficult for the Regional Office, within its resources, to
develop and manage such networks of collaborating centres;
this would be one of the main tasks of the proposed European
Centre for Environment and Health.

The Centre is expected to serve as a clearing-house for

environmental data and information. Another important
task would be to develop and coordinate multicentre activ-
ities. The Regional Office has already demonstrated the
value of these activities in epidemiological studies of low-
level exposure to environmental hazards. Steps would be
taken to secure close cooperation with other international
organizations, and the role and functions of the environ-
mental agency to be established within the European Com-
munities would be fully taken into account.

Promoting the Charter

The Charter can only succeed if its principles are adopted

and all necessary action is taken to attain its objectives in all
countries of the European Region. The Charter should
therefore be promoted both by Member States and by WHO
on a continuing basis, so that in all sectors of society the
Charter becomes regarded as an important basis for future
action on environment and health.

Follow-up Conference

The Charter proposes that Ministers of Environment and of

Health in Europe meet again within five years to evaluate

102
national and international progress and to endorse plans
drawn up by WHO and other international organizations for
specific action to eliminate the most significant environ-
mental threats to health as rapidly as possible. In 1991, the
proposed European Advisory Committee on the Environ-
ment and Health might decide when to hold the Second
European Conference on Environment and Health.

103
ANNEXES
Annex 1

Relevant European
Health for All Targets

The environment of the European Region is changing rapidly

in terms of demographic structure, human lifestyles, con-
sumer goods, energy sources, modes of industrial and agri-
cultural production, transportation, tourism and migration.
All these factors can cause, and can interact to produce,
major impacts on health.
An important aspect of preventive health care is to ensure
that socioeconomic development is carried out in such a way
as to protect, and where possible enhance, human health and
wellbeing. In addition to safeguards in relation to new
socioeconomic development, there is a need for improve-
ments in the existing human environment, including the
upgrading of housing, the reduction of longstanding pol-
lution and the provision of better working conditions.
Such measures involve many aspects of government, at
central, regional and local levels, and require well in-
tegrated, multisectoral planning and management. Because
many of the problems, such as air and water pollution and the
transportation of potentially harmful materials, may affect
more than one country, there is a need for international
collaboration on surveillance and control measures.
The development of new technologies, e.g. in the
areas of energy production or chemical manufacture, must
be such that it minimizes the potential adverse effects on

106
human health, and this requires the establishment of
systematic mechanisms for risk assessment and the study
of alternatives.
While rapid socioeconomic development has brought
about substantial changes in the European environment,
some countries still have major problems of water supply
and sanitation, whose solution could lead to a major re-
duction in the incidence of enteric diseases, particularly
those affecting children.
Environmental management should aim not only at safe-
guarding human health from the potential adverse effects of
biological, chemical and physical factors, but also at en-
hancing the quality of life by, among other things, providing
people with clean water and air, pleasant living and working
conditions and ample facilities for leisure pursuits. All are
factors that can have substantial positive effects on health
and wellbeing.
In all countries of the European Region, there is now
widespread interest in the quality of the environment and in
its influence on human health. Attainment of the targets in
this chapter will be facilitated by the provision of infor-
mation on the issues involved, and by promoting community
and individual participation.

Target 11 : Accidents

By the year 2000, deaths from accidents in the Region

should be reduced by at least 25% through an intensified
effort to reduce traffic, home and occupational accidents.
This target could be achieved if, by the year 2000, no
country had a mortality rate from road traffic accidents of

107
 more than 20 per 100 000; if countries below that level
reduced it to less than 15; if all countries reduced the
differences between the sexes, and age and socioecon-
omic groups; furthermore, if the occupational accident
mortality in the Region were lowered by at least 50%;
and if the mortality from home accidents were signifi-
cantly reduced.

Problem statement
Accidents constitute the third leading cause of death in the
Region, with a mortality rate of about 50 per 100 000. About
50% of accidental deaths occur in the age group 15-64, and
they account for 50% of all deaths in men aged 15-24.
The number of accidental deaths varies considerably
among countries of the Region. Among those for which data
are available, the death rates range from 30 to 65 per
100 000 people. There is also a considerable variation
within countries. In fact, accidents are one of the causes of
death for which the difference between socioeconomic
groups is most significant.
In developed countries, the number of accidental deaths
and injuries has declined over recent years. However, the
relative importance of accidents as a cause of death and
injury is growing, especially among children, young people
and the elderly. In developing countries, the numbers of ac-
cidents, accidental deaths and injuries are rising as a con-
sequence of increasing industrialization and greater use of
motor vehicles.
Motor vehicle accidents account for about 40% of acci-
dental deaths. Death rates from such accidents in Member
States range from 9 to 30 per 100 000 population, although

108
20 countries have registered an overall reduction of 15% in
traffic fatalities since 1974. For every death in a road
accident, there are about 15 cases of severe injury and 30 of
slight injury. Motor vehicle accidents are thus an important
cause of hospitalization and a major factor in permanent
disability. They entail the use of complex and costly tech-
nology for treatment as well as medicaVsocial services for
the care of the disabled.
Accidental poisoning, falls and fires produce a combined
death rate of close to 25 per 100 000 and account for about
45% of all accidental deaths. Although the available in-
formation does not allow precise identification of the places
where accidents occur, those in the home appear to be an
important cause of death in the Region.
Accidents at work are still an important cause of disabil-
ity and death. The available data indicate that in highly
industrialized countries the annual rate of reported occu-
pational accidents is about 6 per 100 working people. Acci-
dents on the way to and from work are about one tenth as
frequent as those that occur at work. The reported death rate
varies from 2 to over 10 per 100 000. As many as 10% of
these accidents result in permanent disability, and they are
six times more frequent in men than in women.
During the past 10 years, some countries have achieved a
sizeable reduction of fatal accidents at work. However, the
general trend in Europe has been towards only a limited or no
reduction of accident frequency.

Suggested solutions

In the prevention of accidents, multidisciplinary and in-

tersectoral policies and programmes should be developed

109
with a view to determining and then eliminating or reducing
hazards, especially in the home, on the roads and at work,
and to designing safer goods. In view of the large and
increasing trade in motor vehicles, encouragement should be
given to the adoption of internationally agreed vehicle de-
sign changes that will improve health and safety and give
better protection to occupants. More effective traffic control
and safety education for road users, better roads, improve-
ments in the design of machinery, child-proof containers for
medicines, building codes, fire codes, protective devices
and other forms of occupational hazards control are some of
the safety measures that would help to reduce accidents.
Legislation and economic incentives should be established
to encourage the design and marketing of safer products.
Consumer products should be systematically tested from the
point of view of health and safety, and the results made
widely available to consumers.

The health sector should play an important role in in-

creasing an awareness of risks among politicians, planners,
professionals and consumers. Systems for epidemiological
surveillance, contingency planning and response to acci-
dents, including man-made and natural disasters, should be
developed in all countries, with suitable machinery to deal
with major emergencies that might affect more than one
Member State.

Consideration should be given to improving the system

of information on accidents so as to state the place of
occurrence in each case. This would allow better identifi-
cation of the causes of domestic accidents as well as of those
people who are most at risk, and thus give important feed-
back for the development of intervention programmes.

110
Target 18: Multisectoral Policies

By 1990, Member States should have multisectoral

policies that effectively protect the environment from
health hazards, ensure community awareness and in-
volvement, and support international efforts to curb such
hazards affecting more than one country.
The achievement of this target will require the acceptance
by all governments that well coordinated multisectoral
efforts are needed at central, regional and local levels, to
ensure that human health considerations are regarded as
essential prerequisites for industrial and other forms of
socioeconomic development, including the introduction
of new technologies; the introduction of mechanisms to
increase community awareness and involvement in en-
vironmental issues with potential implications for human
health; and the development of international arrange-
ments for effective control of transfrontier environmental
health hazards.

Problem statement
Preventive health care involves many matters of concern to
governments, within the fields of physical planning,
housing, industry, agriculture, transport, energy production
and environmental protection. At present there is sometimes
a lack of a multisectoral approach towards environmental
health management, and an absence of effective coordi-
nation to ensure that socioeconomic development is not
accompanied by detrimental effects on the health and well-
being of the population. In addition, in some countries there
is an overlap of functions, with two or more ministries or

111
government agencies engaged in closely related work that
could be performed more effectively by a single body.
Particularly since the Conference on Man and the Envi-
ronment in Stockholm in 1972, there has been increasing
concern in all countries of the Region about the impact of
environmental hazards on human health, but the public are
often confused and worried about the nature of such hazards,
both in the workplace and in the general environment. In
some countries, insufficient efforts have been made to pro-
mote community awareness of or involvement in such is-
sues.
Increasingly, potentially hazardous goods and wastes are
being transported across national boundaries, and hence
air and water pollution may affect states other than the
country of origin. Industrial development close to frontiers
can pose particular problems. Moreover, continuing trends
in the migration of workers and international travel can lead
to an increased probability of infections reaching other
countries.

Suggested solutions
This target will be achieved only if governments regard
environmental health concerns as mandatory elements of
socioeconomic development. This means that there should
be adequate legislation in all areas affecting the environ-
ment, an increased awareness throughout society of possible
environmental hazards and how to protect against them,
more concern for health factors when planning for new
developments, a free flow of information and public in-
volvement in these issues, and more international collabor-
ation on transfrontier problems.

112
 Effective legislation and permanent machinery will need
to be established to ensure that all sectors of national,
subnational and local government, including those con-
cerned with physical planning, housing, industry, agri-
culture, energy production and environmental protection,
take health considerations fully into account at the planning
stage of new developments. Intensive efforts are required
to ensure that development takes place in forms that mini-
mize environmental hazards and enhance human health and
wellbeing.

The achievement of a significant reduction in health risk

due to environmental factors will require increased aware-
ness among all exposed groups, "risk producers", all cate-
gories of professionals involved, and the general public as to
the nature and extent of risks and effective means of pro-
tection against them.

Greater awareness of environmental hazards will in-

crease the desire for safety and promote more active and
enlightened public involvement in the issues. This in turn
should lead decision-makers to exercise greater care in
ensuring that environmental health considerations are
taken fully into account when planning and assessing new
developments.

Much attention should therefore be given to producing

material that provides information on health concerns and
existing risk factors for the general public, particularly at the
community level. The community should also be given a
decisive voice in decisions affecting its environment. This
could be done, for example, through representatives on local
health councils with strong mandates.

113
 All countries will need to give support to agreements to
control the transfrontier pollution of air and water and the
international movement of hazardous goods and wastes.
Examples of existing cooperation are the Convention on
Long-Range Transboundary Air Pollution and the Con-
vention for the Protection of the Mediterranean Sea
against Pollution, in whose implementation the WHO Re-
gional Office for Europe is collaborating closely with
Member States and with the other international organiz-
ations concerned.

Target 19: Monitoring and Control Mechanisms

By 1990, all Member States should have adequate ma-

chinery for the monitoring, assessment and control of
environmental hazards which pose a threat to human
health, including potentially toxic chemicals, radiation,
harmful consumer goods and biological agents.
The achievement of this target will require the establish-
ment of well coordinated monitoring programmes with
clearly defined objectives; the development of method-
ologies and health criteria for the assessment of data in
relation to control procedures; the investment of ade-
quate levels of funding for control measures, and their
introduction and maintenance; and the training and
utilization of sufficient numbers of competent personnel
for all aspects of environmental health protection.

Problem statement
CHEMicALS. The possibility of health hazards arising from
chemical, physical and biological factors is a major concern

114
in all countries of the European Region. A total of about
60 000 chemicals are produced commercially, and be-
tween 200 and 1000 new compounds are introduced each
year. A high proportion have not caused any discernible
adverse effects. However, although some toxicity infor-
mation is available for many of the products, there is very
little relating to human health risk assessment. For example,
the International Agency for Research on Cancer has evalu-
ated nearly 600 chemicals and industrial processes, and
found some 30 to be causally associated with cancer in
humans. Furthermore, cancer is only one of a variety of the
potential toxic insults from chemicals that can cause acute
toxic effects, congenital abnormalities, skin lesions, neuro-
logical disorders, behavioural abnormalities, immunologi-
cal damage and mutagenic effects.
IoNIZING RADIATION. The adverse effects of ionizing radiation
on human health, particularly in relation to cancer, have
been clearly demonstrated. Mishaps have occurred only
when technical knowledge has been inadequately applied to
the design and operation of plant and equipment. It is not
always appreciated that the greatest public exposure to
ionizing radiation is from medical X-rays, and attention is
being paid to the limitations of diagnostic procedures in
many countries.
NOISE. Noise is increasing in urban and industrial areas with
an estimated 10-20% of the European population exposed to
sound well above acceptable levels. It is forecast that
community noise levels in the Region will increase by 30%
by the year 2000 unless more stringent controls are imposed.
BIOLOGICAL AGENTS. These take a great public health toll,
particularly in the Mediterranean area of the Region. In-
adequate sanitation has led not only to diarrhoeal diseases,

115
which are the major cause of morbidity and mortality in
infants in that area, but also to endemic typhoid and cholera.
As regards tropical diseases, there were 116 000 cases of
malaria in one country in 1977, schistosomiasis is still a
problem and leishmaniasis is returning. In some European
countries with good reporting systems, the incidence of food
poisoning has shown a sharp increase in the last 10 years,
and it is often associated with new methods of production,
storage and preparation. Finally, the considerable damage
caused by insects and rodents not only as disease carriers but
as destroyers of food must be recognized.

CoNSUMER oooos. An ever-increasing range of consumer

goods is available to the public. A small proportion are
unsafe, either because they are badly designed or con-
structed or contain potentially dangerous materials, or be-
cause they can readily be misused.

RisK ASSESSMENT. There are widespread uncertainties and

misconceptions about the magnitude and probability of dif-
ferent types of risk, and conjecture about impairments to
health resulting from exposure to chemicals and radiation
and to unsafe consumer products has become a regular
feature of the mass media. Public concern often differs
markedly in respect of risks that are sustained individually,
such as smoking, and those that affect the community, such
as occupational conditions or pollution of air and water.
Fears in the latter category frequently result in suspicion of
or opposition to certain kinds of technological development,
and in the past the lack of effective health safeguards has
sometimes justified such negative responses. Decisions
have frequently been made in a way that does not allow
community involvement.

116
 The risk to health ansmg from the contamination of
water, air, soil and food is often difficult to assess precisely.
Specific episodes of high-level pollution, resulting in wide-
spread contamination, have attracted considerable attention,
but much less is currently known about the cumulative risk
of low-level, long-term contamination, including the com-
bined effects of exposure to a number of different hazards.
Although there have been major efforts in all countries of
the Region to monitor and control the adverse health effects
of unsatisfactory environmental conditions, such measures
have often been incomplete and fragmented, with a lack of
anticipatory action which could have prevented the con-
ditions from arising in the first place.

Suggested solutions
To understand the potential impact of environmental hazards
on human health, there is a need for carefully designed
monitoring strategies, involving as appropriate the measure-
ment of levels of contaminants, the tracing of path-
ways of contamination in the environment, the estimation of
personal exposures and accumulations in tissue, and the per-
formance of epidemiological studies. Assessment of po-
tential health effects will involve the use of the results of
investigations together with toxicological information,
which is often based on experiments in other species. Use
should also be made of internationally developed health
criteria in developing limits of exposure.
Control strategies may provide for legislative, economic
and technical measures, together with education and train-
ing, and they would frequently involve more than one sector
of government. Efforts should be directed especially to
the development of procedures whereby potential adverse

117
effects on health can be anticipated and prevented at the
planning and design stages of new development. Such
measures should be counted as part of the cost of such de-
velopment, since prevention is almost invariably cheaper
than later cure. When control equipment is introduced,
e.g. to reduce the levels of harmful emissions, it must be ef-
ficiently operated and maintained by appropriately trained
personnel.
When possible, technologies with a low impact on human
health and the environment should be adopted. So far as
possible, waste materials should be recycled and reused.
An important requirement for the satisfactory control of
environmental health hazards is the establishment of a well
trained corps of inspectors who, with the backing of sound
and practical legislation, can not only monitor and seek to
remedy harmful conditions, but also give expert advice on
both preventive and curative measures.
Because of the international nature of many environ-
mental health problems, there is a clear need for collabor-
ation among countries in relation to both monitoring and
control. In addition, because the available human and
financial resources are limited, risk assessment for par-
ticular hazards, such as new chemicals, can often be best
done through international endeavours.

Target 20: Control of Water Pollution

By 1990, all people of the Region should have adequate

supplies of safe drinking-wate1; and by the year 1995
pollution of rivers, lakes and seas should no longer pose
a threat to human health.

118
 The achievement of this target will require, in the less
developed countries of the Region, the investment of
higher levels of funding for the construction and mainte-
nance of drinking-water supply facilities, with the appro-
priate mobilization of international and bilateral assist-
ance to reinforce national endeavours, and with the train-
ing and utilization of adequate numbers of competent
personnel; and in all countries of the Region, the intro-
duction of effective legislative, administrative and tech-
nical measures for the surveillance and control of pollu-
tion of surface water and ground water, in order to comply
with criteria to safeguard public health.
Problem statement
The recognition that safe water and sanitation are essential
for the protection of human health led to the adoption by the
United Nations General Assembly of resolution 35/18 on the
International Drinking Water Supply and Sanitation Decade.
Water-related diseases are an important public health prob-
lem and a major cause of death of young children in devel-
oping countries. It is estimated that over 100 million people
in the Region are without an acceptable water supply and
250 million without adequate sanitation. Even in the most
advanced Mediterranean countries, some 10% of all children's
admissions to hospital are due to diarrhoea} disease. Water-
related vectorborne diseases (malaria, schistosomiasis) are
on the increase in some areas of the Region. Population
growth and the sudden influx of tourism in the wanner
countries have added to the demand for safe water supplies.
Even in the more developed parts of the Region, there
are still serious deficiencies in water supply and sani-
tation, particularly in rural areas, and it is estimated that

119
about 35 million people lack safe water and 100 million
adequate sewerage. Any defective supply system, whether
the shortcoming is in the form of leakage or discontinuity of
service or poor operation and maintenance, is a potential
danger to health. Every effort should therefore be made
to ensure that all systems remain in continuous and
effective operation, and disinfection will play a key role in
this respect.
Owing to increased demands on limited water resources,
an ever greater proportion of public supplies is being drawn
from lowland rivers and groundwaters that are subject to
pollution by a growing range of potentially toxic substances
from domestic, industrial and agricultural sources. Ground-
water is particularly difficult to rehabilitate once contami-
nation has occurred. Natural occurrences of substances such
as arsenic and excessive concentrations of fluorides may
pose a public health problem, and the degree of softness of
the water is even considered to be a factor in cardiovascular
disease. In older communities with plumbing systems in
lead, appreciable concentrations of this element can occur
in the water. Some forms of treatment of public water
supplies can result in the production of potentially harmful
substances.
Control of pollution of major water resources is not
always the responsibility of a single nation. When rivers
cross or constitute international borders, or where large
aquifers are shared by countries, international collaboration
becomes essential.
The contamination of rivers, lakes and coastal waters
may represent a hazard when they are used for water supply,
bathing or aquaculture. Enteric diseases and hepatitis have

120
been associated with swimming in polluted Mediterranean
waters, and the consumption of seafood harvested from
contaminated areas has resulted in many cases of infection.
On the other hand, unpolluted waters can represent an
important, health-enhancing recreational resource.

Suggested solutions
This target could be achieved if all countries ensured that the
whole population was served by supplies conforming to the
WHO guidelines for drinking-water quality and that effec-
tive steps were taken to protect both fresh and marine waters
from pollution.
Specific measures to reach this target would include the
investment of sufficient funds to provide adequate supplies
of safe drinking-water for the population, and the effective
management or maintenance of collection, treatment and
distribution systems. It will be necessary to draw up coun-
trywide strategies on the protection of water resources as
part of overall water management, and to entrust their imple-
mentation to effective pollution control authorities. Par-
ticular stress should be laid on preventing groundwater
pollution and the leakage of potentially toxic materials from
non-point sources and from hazardous waste dumping sites.
Physical planning and land-use management may also have
an important influence on water quality. Finally, agri-
cultural practices that can be detrimental to water quality
need to be controlled.
Achievement of the targets would be facilitated by the
adoption of internationally binding agreements on the devel-
opment and implementation by all coastal countries of
measures to protect the quality of seawater, particularly in

121
areas where there are bathing beaches or where seafood is
harvested. Protocols and agreements on pollution control,
between countries sharing water resources, are also an im-
portant requirement.

Target 21: Control of Air Pollution

By 1995, all people of the Region should be effec-

tively protected against recognized health risks from air
pollution.
The achievement of this target will require the intro-
duction of effective legislative, administrative and tech-
nical measures for the surveillance and control of both
outdoor and indoor air pollution, in order to comply with
criteria to safeguard human health.

Problem statement

In extreme instances, acute episodes of air pollution have

been shown to cause serious illness and loss of life. Less is
known about the consequences of long-term exposure to low
concentrations of contaminants, although the adverse health
effects of sulfur oxides and particulates, nitrogen oxides and
oxidants and hydrocarbons, for example, are recognized.
Greater use of fossil fuels, particularly coal and oil for
energy production and transportation, has led to consider-
able increases in the discharge of sulfur and nitrogen oxides.
Vehicular traffic in European countries has increased by at
least 30% in the last 10 years, producing harmful emissions
with both a direct and an indirect impact on human health.
The transboundary migration of sulfur and nitrogen oxides,

122
together with other pollutants and acid rain, are causing
increasing concern in northern and central Europe.
Long-term climatic changes resulting from air pollution
may ultimately have an influence on human health and well-
being, particularly in terms of the direct effects of increased
carbon dioxide emissions on atmospheric temperature and
the possible effect of the reduction of the ozone layer due to
aerosol propellants on the incidence of skin cancers.
Indoor air pollution by substances originating outdoors,
emitted by building materials or generated by man and his
indoor activities, is a problem that is becoming more acute as
new materials are introduced and ventilation is reduced to
save energy.

Suggested solutions

The attainment of this target would require the strengthening

of measures in Member States for control of emissions from
industry, domestic premises and motor vehicles, and a sub-
stantial reduction in indoor air pollutants. Legislative, econ-
omic and technical measures based on internationally ac-
cepted criteria will be needed for this purpose. In some
cases, air pollution would be substantially reduced by the
use of alternative raw materials or technologies or the modi-
fication of production processes. More effective inter-
national agreements would progressively enable adequate
control of long-range air pollutants, such as sulfur and
nitrogen oxides. More systematic investigations, inter alia
in the form of epidemiological surveillance, should be car-
ried out in accordance with internationally agreed protocols
in order to determine the long-term health effects of air
pollutants.

123
Target 22: Food Safety

By 1990, all Member States should have significantly

reduced health risks from food contamination and im-
plemented measures to protect consumers from harmful
additives.
The achievement of this target will require the intro-
duction of effective legislative, administrative and tech-
nical measures for the surveillance and control of food
contamination at all stages of production, distribution,
storage, sale and use; and the implementation of
measures to control the use of harmful food additives.

Problem statement
The reporting of foodbome infections is inadequate, and it is
estimated that no more than 5% of acute incidents are
notified in most countries. The relationship between such
diseases and the availability of safe drinking-water and
sanitation is well established.
Chemicals, whether from natural, industrial or agri-
cultural sources, can adversely affect food safety. The
possible effects range from acute poisoning to carcinogenity
or reproductive damage in the longer term. Although know-
ledge of the effects of the ingestion of low concentrations of
potentially harmful chemicals is limited, it is clear that tech-
nological development is resulting in a steady increase in the
number and range of chemicals to which the population is
exposed. For example, recent programmes for monitoring
cadmium in food have shown European levels to be close to
the weekly permissible dose. In addition, several hundred
chemicals are used as food additives to improve the quality

124
and appearance of prepared foods and, hence, toxicological
evaluation and systematic surveillance are of paramount
importance.
Changing social habits, tourism and the entry of a large
proportion of the female population into the workforce have
led to dramatic changes in the pattern of food consumption.
In some countries, the majority of meals are now produced
outside the home, and thus mass catering has replaced home
cooking, leading to new problems related to changing
methods of food production, storage and preparation.

Suggested solutions
The attainment of this target would involve the design and
strict enforcement of properly coordinated control systems
covering the production, distribution, storage, sale and use
of food, and the employment of well trained and effective
food inspectors and food surveillance teams. Furthermore,
it will be necessary to change public attitudes by means of
information and education and to include food hygiene in all
primary school curricula. In view of the rapidly growing
international trade in food products, food safety regulations
in countries should be based on those agreed internationally.

Target 23: Control of Hazardous Wastes

By 1995, all Member States should have eliminated

major known health risks associated with the disposal of
hazardous wastes.
The achievement of this target will require the intro-
duction of effective legislative, administrative and
technical measures for the surveillance and control of

125
 hazardous wastes; and the introduction of effective
measures to eliminate health risks due to previously
dumped wastes.

Problem statement
Very large quantities of waste are generated within the
European Region. In the member countries of the European
Community, for example, 2000 million tons are produced
annually, including about 30 million tons that are considered
to be hazardous. The chemical industry has expanded
continuously for more than a century and the manufacture of
some of the most important substances has increased by 30%
within the last 10 years; inevitably this has been accom-
panied by a greatly increased production of waste, some of
which could pose a threat to health unless effective disposal
measures are adopted.
A number of major incidents have occurred during recent
years, resulting in gross contamination of soil and ground-
water. At the same time, there have been many less dramatic
cases where unsatisfactory methods of disposal have led to
long-standing pollution as well as health hazards on some
occasions. Clandestine disposal to rivers and public sewers
sometimes occurs, and in the 90% of cases where hazardous
wastes are dumped, the contents and even the location of
disposal are unknown to the authorities.
In some countries, pesticides are frequently handled
without proper care, and partly filled containers may be left
to rot. Facilities are not always available for the collection
and safe disposal of hazardous consumer products such as
waste oil and household chemicals. Potentially toxic
materials are often transported and stored without clear

126
labelling and without adequate precautions to prevent spills
or seepage. In some countries, there are no arrangements for
educating the users as to potential dangers.

Suggested solutions

This target could be achieved if all countries adopted com-

prehensive legislative, administrative, technical and edu-
cational measures for the safe handling, transportation and
disposal of hazardous wastes, including effective inter-
national agreements relating to transfrontier shipment. In
some cases, technical measures will include the recycling of
wastes, the manufacture of useful by-products, alternative
methods of production or the selection of alternative raw
materials. In some places, measures will be needed to
eliminate risks due to wastes dumped (sometimes many
years) previously.

Target 24: Human Settlements and Housing

By the year 2000, all people of the Region should have a

better opportunity of living in houses and settlements
which provide a healthy and safe environment.
The achievement of this target will require the acceler-
ation of programmes of housing construction and im-
provement; the development of international health cri-
teria for housing, space, heating, lighting, disposal of
wastes, noise control and safety, while taking into ac-
count the special needs of groups such as young families,
the elderly and the disabled; legislative, administrative
and technical measures to comply with such criteria; the
improvement of community planning in order to enhance

127
 health and wellbeing by improving traffic safety, pro-
viding open spaces and recreational areas, and facilitat-
ing human interaction, etc.; and the equipment of all
dwellings with proper sanitation facilities and the pro-
vision of sewers and an adequate public cleansing and
wastes collection and disposal system in all human settle-
ments of sufficient size.

Problem statement
The environment of human settlements is a basic factor
governing the physical and mental health, the social well-
being and, generally, the quality of life of the people who
live in them. Despite much improvement during the last few
decades, environmental health conditions in many cities,
towns and villages in the European Region, and in particular
housing conditions, are often totally inadequate. Some large
settlements are still not fully sewered or do not have an
efficient service for public cleansing or for liquid and/or
solid wastes collection and disposal.
The level of hygiene in human dwellings is a very im-
portant environmental health factor especially for those who
spend most of their time indoors, such as infants, young
children, the elderly and the handicapped. For better or for
worse, housing conditions affect everybody's physical and
mental health and wellbeing; yet today, many millions of
people in Europe still live in dwellings that are grossly
substandard. It has been estimated that 34% of the popu-
lation have less than 8m2 of floor space, 42% of dwellings
are inadequately heated, and 27% are without basic sani-
tation. In some countries, a majority of the population do not
have a flush toilet, and in some parts of the Region millions
live in shanty towns.

128
 The population growth rate of the Region as a whole is
projected at 0.5--0.7% up to the year 2000. However, in
some areas, especially around the Mediterranean, the rate is
much higher. At the same time, there is a steady movement
of people from rural to urban areas, thus increasing the
pressure on housing in towns and cities. The incidence of
respiratory diseases is considered to be related to such
housing features as air quality and density of occupation. In
Mediterranean countries, there is a significant link between
poor housing and both tuberculosis and enteric diseases.

In some cases, social trends have led to the decay of inner

city areas, with its consequences of overcrowding, in-
adequate hygiene, noise pollution, traffic hazards and a total
lack of facilities for health promotion. Migration patterns
have placed an increased burden on housing in some places.
Areas in the vicinity of poor housing are often derelict and
open to infestation by stray animals, rodents and insects.

The mentally depressing effects of living in dirty, drab

and monotonous environments are difficult to quantify
but are clearly important in relation to human health and
wellbeing.

In developed countries, the advent of air conditioning and

energy conservation measures have been accompanied by
growing problems of indoor air quality. Potentially harmful
levels of nitrogen oxides, tobacco smoke, formaldehyde and
radon can be found in homes. Some pollutants arise from
insulation products, some from kerosene heaters, and others
from modem housing materials. As many Europeans spend
up to 90% of their lives in buildings, the health effects of the
indoor climate are significant.

129
 In all parts of the Region, there is an unacceptably high
incidence of accidents in the home leading to considerable
mortality and disability.

Suggested solutions
The situation could be substantially improved if all countries
took effective measures to reduce overcrowding in houses,
to ensure the provision of adequate means of heating, light-
ing, cooking and hygienic disposal of wastes, and to reduce
community noise to acceptable levels.
Effective and enlightened community planning could
have a major impact on the creation of a healthy environ-
ment, by such measures as traffic safety, adequate collection
and disposal of solid and liquid wastes, the provision of
recreational areas and the facilitation of human contact and
interaction. In many countries, the health sector should be
more directly involved in housing and settlement planning.
Minimum standards should be set in relation to the health
aspects of housing, including provisions on hygiene, safety,
space, lighting and both noise and thermal insulation. Cri-
teria for indoor air quality should also be established. In
accordance with the goals of the International Drinking
Water Supply and Sanitation Decade, all dwellings should
not only have a supply of safe water but also adequate means
for the hygienic disposal of wastes.
A special effort should be made to ensure that building
designs meet the needs of the disabled and the elderly and
the requirements of harmonious family life. Comprehensive
measures, including specifications for the safe design and
construction of buildings, furniture, fittings and domestic
equipment, together with continuing education programmes,

130
should be introduced with a view to substantially reducing
the incidence of home accidents.

Target 25: Working Environment

By 1995, people of the Region should be effectively

protected against work-related health risks.
The achievement of this target will require the intro-
duction of appropriate occupational health services to
cover the needs of all workers; the development of health
criteria for the protection of workers against biological,
chemical and physical hazards; the implementation of
technical and educational measures to reduce work-
related risk factors; and the safeguarding of specially
vulnerable groups of workers.

Problem statement
Satisfying work in a safe and pleasant environment is a
source of health and wellbeing. Yet, the physical and
psychological working environment is all too often re-
sponsible for diseases and injuries.
Many workers are exposed to toxic chemicals, harmful
dusts and fibres, noise, and the hazards of fatal or disabling
accidents. In some European countries over the last 10
years, there has been little reduction in the incidence of
accidents at the workplace. In certain industries, such as
mining, quarrying or construction, there are remarkable
variations among the countries of the Region with regard to
the frequency of accidents per number of hours worked,
apparently due mainly to differences in the effectiveness of

131
regulations and safety education of workers. The self-
employed and workers such as those on farms, on con-
struction sites and in small manufacturing plants are often at
most risk.
The total incidence of occupational disease in the Region
is unrecorded, although information is available ou the
effects of particular substances, such as lead, arsenic, as-
bestos and vinyl chloride, and of processes such as coal
mining, stone quarrying and furniture making. Deaths from
occupational diseases such as asbestosis, silicosis, pneu-
moconiosis and byssinosis are recorded in some coun-
tries. Individual behaviour such as smoking can greatly
increase the risk of health damage due to occupational
exposure.
As a result of the increasing employment of women, who
currently represent 30-40% of the civilian workforce in
Europe, there is now an interest in identifying and con-
trolling the potential effects of chemicals on reproduc-
tive processes, both male and female. Mental disorders, hy-
pertensive diseases and myocardial infarction have
sometimes been linked to psychological and social stress
associated with certain working conditions, changes in those
conditions and unemployment. Noise levels can have a dis-
turbing effect on workers and result in severe physical
impairment.
In most countries of the Region, occupational health
records are inadequate, and it is not possible to establish
clear links between them and the overall morbidity and
mortality statistics. Coordination between occupational
health services and the rest of the health care system is often
unsatisfactory.

132
Suggested solutions

This target could be achieved by ensuring that occupational

health services cover the needs of all workers, with reporting
systems that facilitate identification of hazards, assessment
of risk and evaluation of the effectiveness of control
measures.
Occupational health services should cover all places of
work, including the home. In some countries, it will be
necessary to introduce or intensify training programmes for
the various categories of personnel required. It is important
that workers, employers and the general public should be
involved in developing and should receive guidance on ways
to improve working conditions and prevent occupational
risks, including reference to the association between such
risks and personal behaviour such as smoking.
Legislation, economic incentives and improved em-
ployer/employee cooperation should facilitate health pro-
motion and risk prevention. In particular, the registration of
workers and the recording of workplace exposure to po-
tentially harmful processes and materials should make it
easier to take preventive action. Special attention will have
to be paid to high-risk vulnerable groups. Measures to
reduce risks should include the introduction of safer pro-
cedures and in some cases the replacement or strict control
of chemicals known to be dangerous, especially those having
carcinogenic, teratogenic or mutagenic effects.
Methods and procedures for monitoring chemicals, dusts,
fibres and radiation in the workplace will need to be
strengthened. Internationally developed health criteria
concerning all potential hazards should provide the basis for

133
the assessment of risks and the establishment of control
strategies. Epidemiological studies and surveillance of
workers' health will need to be expanded in many countries
of the Region.
Efforts are needed to improve the linkage between occu-
pational health services and the overall health care system at
all levels, from the highest government authorities to pri-
mary health care units.

134
Annex 2

Resolution 42/187 of the

United Nations General Assembly:
Report of the World Commission
on Environment and Development

The General Assembly,

Concerned about the accelerating deterioration of the
human environment and natural resources and the con-
sequences of that deterioration for economic and social
development,
Believing that sustainable development, which implies
meeting the needs of the present without compromising the
ability of future generations to meet their own needs, should
become a central guiding principle of the United Nations,
Governments and private institutions, organizations and
enterprises,
Recognizing, in view of the global character of major
environmental problems, the common interest of all coun-
tries to pursue policies aimed at sustainable and environ-
mentally sound development,
Convinced of the importance of a reorientation of national
and international policies towards sustainable development
patterns,
Recalling that, in its resolution 38/161 of 19 De-
cember 1983 on the process of preparation of the Environ-
mental Perspective to the Year 2000 and Beyond to be

135
prepared by the Governing Council of the United Nations
Environment Programme, it welcomed the establishment of
a special commission, which later assumed the name World
Commission on Environment and Development, to make
available a report on environment and the global proble-
matique to the year 2000 and beyond, including proposed
strategies for sustainable development,
Recognizing the valuable role played in the preparation
of the report of the World Commission by the Inter-
governmental Inter-sessional Preparatory Committee of the
Governing Council of the United Nations Environment Pro-
gramme, as envisaged by the General Assembly in its res-
olution 38/161,
Recalling that in resolution 38/161 it decided that, on
matters within the purview of the United Nations Environ-
ment Programme, the report of the Commission should in
the first instance be considered by the Governing Council
of the Programme, for transmission to the General Assembly
together with the comment of the Council and for use as
basic material in the preparation, for adoption by the Assem-
bly, of the Environmental Perspective and that on those
matters which were under consideration or review by the
Assembly itself, it would consider the relevant aspects of the
report of the Commission,
Taking note of Governing Council decision 14/14 of
19 June 1987 transmitting the report of the Commission to
the General Assembly,
Noting that the Environmental Perspective to the Year
2000 and Beyond has taken account of the main recommen-
dations contained in the report of the Commission,

136
 Recognizing the instrumental role of the Commission in
revitalizing and reorienting discussions and deliberations on
environment and development and in enhancing the under-
standing of the causes of present environmental and devel-
opmental problems, as well as in demonstrating the ways in
which they transcend institutional frontiers and in opening
new perspectives on the interrelationship between environ-
ment and development as a guide to the future,
Emphasizing the need for a new approach to economic
growth, as an essential prerequisite for eradication of poverty
and for enhancing the resource base on which present and
future generations depend,
1. Welcomes the report of the World Commission on Environ-
ment and Development entitled "Our Common Future";
2. Notes with appreciation the important contribution made
by the Commission to raising the consciousness of decision-
makers in Governments, intergovernmental and nongovem-
mental international organizations, industry and other fields
of economic activity, as well as of the general public, in
regard to the imperative need for making the transition
towards sustainable development, and calls upon all con-
cerned to make full use in this regard of the report of the
Commission;
3. Agrees with the Commission that while seeking to remedy
existing environmental problems, it is imperative to in-
fluence the sources of those problems in human activity, and
economic activity in particular, and thus to provide for
sustainable development;
4. Agrees further that an equitable sharing of the environ-
mental costs and benefits of economic development between

137
and within countries and between present and future gener-
ations is a key to achieving sustainable development;
5. Concurs with the Commission that the critical objec-
tives for environment and development policies which fol-
low from the need for sustainable development must include
preserving peace, reviving growth and changing its quality,
remedying the problems of poverty and satisfying human
needs, addressing the problems of population growth and of
conserving and enhancing the resource base, reorienting
technology and managing risk, and merging environment
and economics in decision-making;
6. Decides to transmit the report of the Commission to all
Governments and to the governing bodies of the organs,
organizations and programmes of the United Nations sys-
tem, and invites them to take account of the analysis and
recommendations contained in the report of the Commission
in determining their policies and programmes;
7. Calls upon all Governments to ask their central and
sectoral economic agencies to ensure that their policies,
programmes and budgets encourage sustainable develop-
ment and to strengthen the role of their environmental and
natural resource agencies in advising and assisting central
and sectoral agencies in that task;
8. Calls upon the governing bodies of the organs, organiz-
ations and programmes of the United Nations system to
review their policies, programmes, budgets and activities
aimed at contributing to sustainable development;
9. Calls upon the governing bodies of other relevant multi-
lateral development assistance and financial institutions to
commit their institutions more fully to pursuing sustainable

138
development in establishing their policies and programmes
in accordance with the national development plans, pri-
orities and objectives established by the recipient Govern-
ments themselves;
10. Requests the Secretary-General, through the appro-
priate existing mechanisms, including the Administrative
Committee on Co-ordination, to review and coordinate
on a regular basis the efforts of all the organs, organizations
and bodies of the United Nations system to pursue sus-
tainable development, and to report thereon to the General
Assembly through the Governing Council of the United
Nations Environment Programme and the Economic and
Social Council;
11. Stresses the essential role of the United Nations En-
vironment Programme, within its mandate, in catalysing the
sustainable development efforts of the United Nations sys-
tem, while fully taking into account the coordinating re-
sponsibilities of the Economic and Social Council, and
agrees with the Commission that that role should be
strengthened and that the resources of the Environment Fund
should be substantially enlarged, with greater participation;
12. Considers that the Governing Council of the United
Nations Environment Programme, within its mandate and
with participation, when appropriate, at the ministerial level,
should examine on a periodic basis the long-term strategies
for realizing sustainable development, and should include
the results of its examinations in its reports to be submitted
to the General Assembly through the Economic and Social
Council;
13. Agrees that the catalytic and co-ordinating role of the
United Nations Environment Programme in the United

139
Nations system should be reinforced in its future work on
environmental and natural resource issues;

14. Reaffirms the need for additional financial resources

from donor countries and organizations to assist developing
countries in identifying, analysing, monitoring, preventing
and managing environmental problems in accordance with
their national development plans, priorities and objectives;

15. Reaffirms the need for developed countries and appro-

priate organs and organizations of the United Nations system
to strengthen technical co-operation with the developing
countries to enable them to develop and enhance their ca-
pacity for identifying, analysing, monitoring, preventing
and managing environmental problems in accordance with
their national development plans, priorities and objectives;

16. Invites Governments, in co-operation with the re-

gional commissions and the United Nations Environment
Programme and, as appropriate, intergovernmental organiz-
ations, to support and engage in follow-up activities, such as
conferences, at the national, regional, and global levels;

17. Calls upon Governments to involve nongovernmental

organizations, industry and the scientific community more
fully in national and international activities to support ef-
forts towards sustainable development;

18. Invites the governing bodies of the organs, organiz-

ations and programmes of the United Nations system to
report, as appropriate, through the Economic and Social
Council, to the General Assembly, not later than at its forty-
fourth session, on progress made in their organizations
towards sustainable development, and to make such reports

140
available to the Governing Council of the United Nations
Environment Programme at its next regular session;

19. Also invites the Governing Council of the United

Nations Environment Programme to provide comments on
matters concerning progress on sustainable development
that fall within its mandate, on the above-mentioned reports
and on other developments, for submission to the Econ-
omic and Social Council at its second regular session of
1989 and to the General Assembly at its forty-fourth session;
20. Requests the Secretary-General to submit to the
General Assembly at its forty-third session, through the
Economic and Social Council, a progress report on the im-
plementation of the present resolution and to the Assembly
at its forty-fourth session a consolidated report on the same
subject;

21. Decides to include in the provisional agenda of its

forty-third session a sub-item entitled "A long-term strategy
for sustainable and environmentally sound development''
under the agenda item entitled "Development and inter-
national economic cooperation''.

141
Annex 3

Resolution 42/186 of the

United Nations General Assembly:
Environmental Perspective to
the Year 2000 and Beyond

The General Assembly,

Recalling its resolution 38/161 of 19 December 1983 on
the process of preparation of the Environmental Perspective
to the Year 2000 and Beyond, in which it, inter alia, wel-
comed the desire of the Governing Council of the United
Nations Environment Programme to develop the Environ-
mental Perspective and transmit it to the General Assembly
for adoption, benefiting in carrying o~t that function from its
consideration of the relevant proposals made by a special
commission, which adopted the name World Commission on
Environment and Development,
Welcoming the Environmental Perspective to the Year
2000 and Beyond, prepared by the Intergovernmental Inter-
sessional Preparatory Committee on the Environmental
Perspective to the Year 2000 and Beyond of the United
Nations Environment Programme, referred to in General
Assembly resolution 38/161, considered further by the
Governing Council of the United Nations Environment
Programme at its fourteenth session and adopted in its
decision 14/13 of 19 June 1987, as a basis for the further
elaboration of its programme and operations, while ac-
knowledging that different views exist on some aspects,

142
 Appreciating that concepts, ideas and recommendations
contained in the report of the World Commission on En-
vironment and Development have been incorporated into the
Environmental Perspective,

1. Expresses its appreciation for the efforts of the Govern-

ing Council of the United Nations Environment Programme
and its Intergovernmental Inter-sessional Preparatory Com-
mittee on the Environmental Perspective to the Year 2000
and Beyond in the preparation of the Environmental Per-
spective to the Year 2000 and Beyond;

2. Adopts the Environmental Perspective to the Year 2000

and Beyond, contained in the annex to the present resolution,
as a broad framework to guide national action and inter-
national co-operation on policies and programmes aimed at
achieving environmentally sound development, and specifi-
cally as a guide to the preparation of further system-wide
medium-term environment programmes and the medium-
term programmes of the organizations and bodies of the
United Nations system, in the light of Governing Council
decision 14/13;

3. Notes that the perceptions generally shared by Govern-

ments of the nature of environmental problems, and their
interrelations with other international problems, and of the
efforts to deal with them include the following:
(a) An international atmosphere of peace, security and
co-operation, free from the presence and the threat of
wars of all types, especially nuclear war, in which intel-
lectual and natural resources are not wasted on arma-
ments by any nation, would greatly enhance environ-
mentally sound development;

143
 (b) The imbalance of present world economic con-
ditions makes it extremely difficult to bring about sus-
tained improvement in the world's environmental situ-
ation; accelerated and balanced world development and
lasting improvements in the global environment require
improved world economic conditions, especially for the
developing countries;
(c) Since mass poverty is often at the root of environ-
mental degradation, its elimination and ensuring equi-
table access of people to environmental resources are
essential for sustained environmental improvements;
(d) The environment puts constraints on as well as pro-
vides opportunities for economic growth and social well-
being; environmental degradation, in its various forms,
has assumed such proportions as can cause irreversible
changes in ecosystems, which threaten to undermine
human well-being; environmental constraints, however,
are generally relative to the state of technology and
socioeconomic conditions, which can and should be
improved and managed to achieve sustained world econ-
omic growth;
(e) Environmental issues are closely intertwined with
development policies and practices; consequently, en-
vironmental goals and actions need to be defined in
relation to development objectives and policies;
(f) Although it is important to tackle immediate envir-
onmental problems, anticipatory and preventive policies
are the most effective and economical in achieving en-
vironmentally sound development;
(g) The environmental impacts of actions in one sector
are often felt in other sectors; thus internalization of

144
environmental considerations in sectoral policies and
programmes and their co-ordination are essential for the
achievement of sustainable development;

(h) Since conflicts of interest among population groups,

or among countries, are often inherent in the nature of
environmental problems, the participation of the con-
cerned parties is essential in determining effective en-
vironmental management practices;

(i) Environmental degradation can be controlled and

reversed only by ensuring that the parties causing
damage will be accountable for their actions, and that
they will participate, on the basis of full access to avail-
able knowledge, in improving environmental conditions;

(j) Renewable resources, as part of complex and inter-

linked ecosystems, can have sustainable yields only if
used while taking into account system-wide effects of
exploitation;

(k) The safeguarding of species is a moral obligation of

humankind and should improve and sustain human well-
being;

(/) Building awareness at various levels of environ-

mental conditions and management, through the pro-
vision of information, education and training, is essential
for environmental protection and improvement;

(m) Strategies to deal with environmental challenges

have to be flexible and should allow for adjustments to
emerging problems and evolving environmental manage-
ment technology;

145
 (n) International envirorunental disputes, which are
growing in number and variety, need to be resolved by
peaceful means;
4. Welcomes as the overall aspirational goal for the world
community the achievement of sustainable development on
the basis of prudent management of available global re-
sources and envirorunental capacities and the rehabilitation
of the envirorunent previously subjected to degradation and
misuse, and the aspirational goals to the year 2000 and
beyond as set out in the Envirorunental Perspective, namely:
(a) The achievement over time of such a balance be-
tween population and envirorunental capacities as would
make possible sustainable development, keeping in
view the links between population levels, consumption
patterns, poverty and the natural resource base;
(b) The achievement of food security without resource
depletion or environmental degradation and restoration
of the resource base where envirorunental damage has
been occurring;
(c) The provision of sufficient energy at reasonable
cost, notably by increasing access to energy substantially
in the developing countries, to meet current and ex-
panding needs in ways which minimize envirorunental
degradation and risks, conserve nonrenewable sources of
energy and realize the full potential of renewable sources
of energy;
(d) The sustained improvements in levels of living in all
countries, especially the developing countries, through
industrial development that prevents or mmmuzes en-
virorunental damage and risks;

146
 (e) The provision of improved shelter with access to
essential amenities in a clean and secure setting con-
ducive to health and to the prevention of environment-
related diseases, which would, at the same time, alleviate
serious environmental degradation;
(f) The establishment of an equitable system of inter-
national economic relations aimed at achieving continu-
ing economic advancement for all States based on prin-
ciples recognized by the international community, in
order to stimulate and sustain environmentally sound
development, especially in developing countries;
5. Agrees that the recommendations for action contained in
the Environmental Perspective should be implemented, as
appropriate, through national and international action by
Governments, intergovernmental and nongovernmental
organizations and scientific bodies;
6. Requests the Governing Council to keep under review the
extent to which the long-term environmental actions re-
commended in the Environmental Perspective have been im-
plemented and to identify any new environmental concerns
that may arise;
7. Calls special attention to section IV of the Environmental
Perspective, which spells out instruments of environ-
mental action, to be used as support in addressing, as appro-
priate, problems dealt with in previous sections of the En-
vironmental Perspective;
8. Stresses the essential role of the United Nations Environ-
ment Programme within the United Nations system in cata-
lysing environmentally sound and sustainable development
and agrees with the Governing Council that this role should

147
be strengthened and that the resources of the Environ-
ment Fund should be substantially increased with greater
participation;
9. Endorses the priorities and functions for the United
Nations Environment Programme set out in paragraph 117 of
the Environmental Perspective;
10. Decides to transmit the text of the Environmental Per-
spective to all Governments and to the governing bodies of
the organs and organizations of the United Nations system as
a broad framework to guide national action and international
cooperation on policies and programmes aimed at achieving
environmentally sound and sustainable development;
11. Calls upon the governing bodies of the organs and or-
ganizations of the United Nations system to consider the En-
vironmental Perspective and take it into account in the de-
velopment of their own medium-term plans and programmes
as relevant to their own mandates;
12. Requests the governing bodies of relevant United
Nations organizations to report regularly to the General As-
sembly on the progress made in achieving the objectives of
environmentally sound and sustainable development in line
with paragraph 114 of the Environmental Perspective;
13. Invites the Governing Council of the United Nations
Environment Programme to report to the General Assembly
at its forty-fourth session on the implementation of the
present resolution and the relevant provisions of the En-
vironmental Perspective to the Year 2000 and Beyond.

148
Annex 4

Resolution WHA41 .15 of the

World Health Assembly:
Report of the World Commission
on Environment and Development

The Forty-first World Health Assembly,

Welcoming the report of the World Commission on En-
virorunent and Development, entitled Our common future,
and calling particular attention to its conclusions and re-
commendations as they relate to the mandate of WHO;
Noting United Nations General Assembly resolution
42/187 of 11 December 1987, transmitting to all govern-
ments and to the governing bodies of the organs, organiz-
ations and programmes of the United Nations system the
report of the World Commission on Envirorunent and De-
velopment, and inviting them to take account of the analysis
and recommendations contained in the report in determining
their policies and programmes;
Noting further that, in the same resolution, the General
Assembly called upon the governing bodies of the organs,
organizations and programmes of the United Nations system
to review their policies, programmes, budgets and activities
aimed at contributing to sustainable development;
1. REQUESTS the Director-General, the Executive Board and
its Programme Committee, in preparing the programme
budget for the biennium 1990-1991 , to take into account the

149
recommendations in the report of the World Commission on
Environment and Development in all relevant programme
areas, in order to contribute to sustainable development;
2. FuRTHER REQUESTS the Director-General to submit to the
eighty-third session of the Executive Board a progress re-
port on WHO's contribution to the international efforts
towards sustainable development as a contribution to the re-
port to be submitted to the forty-fourth session of the United
Nations General Assembly in accordance with operative
paragraph 18 of General Assembly resolution 42/187.

150
Annex 5

Resolution WHA42.26 of the

World Health Assembly: WHO's
Contribution to the International Efforts
towards Sustainable Development

The Forty-second World Health Assembly,

Having considered the report of the Director-General on

WHO's contribution to the international efforts towards sus-
tainable development;

Recalling resolutions WHA34.36, WHA35.17, WHA39.22

and WHA41.15;

Noting United Nations General Assembly resolutions

42/187, on the report of the World Commission on Environ-
ment and Development, and 42/186, on the Environmental Per-
spective to the Year 2000 and beyond;

Noting also that the United Nations General Assembly will

consider at its forty-fourth session the scope, title, venue
and date of a United Nations conference on environment and
development in 1992;

Considering that equitable health development is an essen-

tial prerequisite for socioeconomic development and that the
sustainable and equitable use of the world's resources will be of
paramount importance for achieving health for all and for the
solution of ecological problems;

151
 Concerned that uncontrolled development and the in-
discriminate use of technology have degraded the environment,
and that this increasingly poses threats to the health of the
present and future generations and the sustainability of the de-
velopment process itself;
Stressing the need for both national and international poli-
cies and strategies dealing with the interdependence between
development, the environment and health;
I. THANKS the Director-General for his report;
2. ENDoRsES the report and the analysis contained therein of the
implications of sustainable development for health and for the
future development of the Organization's programme;
3. URGES Member States:
(1) to establish and evaluate policies and strategies for
preventing adverse effects of development on the environ-
ment and on health;
(2) to strengthen their national health programmes in this
respect, particularly for:
(a) meeting basic human health needs in the context
of development;
(b) providing health care for specific population
groups requiring attention in the development pro-
cess - for example, the urban poor;
(c) preventing diseases resulting from uncontrolled
development;
(d) assessing and preventing the environmental
health risks arising from uncontrolled development
and the indiscriminate use of technology;

152
 (3) to strengthen their national health services to enable
them to play an active role in the context of sustain-
able development;

(4) to adopt appropriate legislation, regulating anthro-

pogenic influences on ecological systems;

4. CALLS ON the international community, including develop-

ment aid agencies and nongovernmental organizations, to in-
crease their support for activities to promote a healthy environ-
ment and to control adverse effects of development on environ-
ment and health;

5. REQUESTS the Director-General:

( 1) to give prominence to the interdependence between

development, the environment and health in WHO's pro-
gramme, emphasizing:
(a) the capability of the Organization to provide
leadership in the identification, assessment and control
of new problems including the health effects of haz-
ardous and toxic substances, industrial processes and
products, agricultural and food processing practices
and climate change;
(b) research and the development of technology for
assessing and controlling the complex interactions be-
tween environmental factors and health;
(c) education and information programmes with a
view to promoting behaviour and lifestyles compatible
with the needs arising from the interdependence be-
tween development, the environment and health;

153
 (2) to support national health agencies in the formulation
of national policies and strategies for, and the im-
plementation of, sustainable and environmentally sound
development;
(3) to ensure the continuation of WHO's advocacy role, in
its collaboration with other international organizations, re-
garding the paramount importance of health considerations
for sustainable development;
(4) to give particular attention to strengthening cooper-
ation between the health and other development sectors, in-
cluding, as appropriate, research on the institutional, econ-
omic and other factors involved;
(5) to collaborate with the Secretary-General of the United
Nations with a view to preparing WHO's contribution to the
forthcoming conference on environment and development;
(6) to report on the progress in this respect to the Forty-
fifth World Health Assembly.

154
The First European Conference on Environment and
Health, held at Frankfurt-am-Main, Federal Republic
of Germany on 7 and 8 December 1989, brought
together ministers and other senior representatives
from the environment and health administrations
of 29 European countries and from
the Commis.,ion of the European Communities.

The Charter, which was adopted by the final session

of the Conference, is a further extension of
the European health for all policy and targets
adopted by the 32 Member States of the European
Region of WHO in 1984. The Charter also
incorporates the basic philosophy of the
World Commis.,ion on Environment and Development,
and represents a major step forward in
the development of both public health and
environmental policies at a time when political change
is greatly enhancing cooperation among
Member States throughout Europe. By adopting
the Charter, the governments of Europe have taken
a united position on the basic principles,
mechanisms and priorities for further developing
environmental health programmes.

This book combines the Charter

and the Commentary, an explanatory text
originally provided as background
for delegations to the Conference and
now given wider dis.,emination at their request.

ISBN 92-890-1126-2 Price: [Link]. 26.-

ISBN 978-92-890-1126-6