Francesco Mitis

Inequalities, inequities, environmental justice in waste management and health

BACKGROUND The scientific evidence on the health effects of waste-related exposure is not conclusive. Differential exposure to waste by socio-economic status (SES) is often documented, but the interplay between environmental and social factors, crucial for policy making, is not well known. This review aims at investigating the role of health inequalities and inequities in waste management. METHODS Grey and peer-reviewed literature, published after 1983, was reviewed from Europe and the USA. RESULTS Available data provide consistent indications that waste facilities are often disproportionally more located in areas with more deprived residents, or from ethnical minorities. This applies to waste incinerators, landfills, hazardous waste sites, legal and illegal. In studies considering health effects (mainly from Europe), risks are estimated with standardization for SES. Such standardization almost always decreases risk estimates for several cancers and reproductive outcomes. However, effect modification is not investigated in these studies. CONCLUSIONS The patterns of association between waste-related environmental pressures and SES suggest that some of the observed inequalities in exposure and health represent a case of environmental injustice as they are the result of social processes and may be prevented, at least partly. Disentangling the possible health effects remains difficult, due to limitations in the methodology. It seems important to investigate if disadvantaged people are more vulnerable, i.e. risks differ in different social groups living in the same area. Notwithstanding these open questions, public health officers and decision makers should identify waste management policies to minimize their potential health impacts and their unequal distribution.

Cancer mortality and congenital anomalies in a region of italy with intense environmental pressure due to waste

Objectives: Waste management in the Campania region has been characterised, since the 1980s, by widespread uncontrolled and illegal practices of waste dumping, generating concerns over the health implications. The objective of this study was to evaluate possible adverse health effects of such environmental pressure. Methods: The health effects of waste-related environmental exposures in Campania were assessed in a correlation study on nine causes of death (for the years 1994–2001) and 12 types of congenital anomaly (CA) (1996–2002) in 196 municipalities of the provinces of Naples and Caserta. Poisson regression was used to analyse the association between health outcomes and environmental contamination due to waste, as measured through a composite index, adjusting for deprivation. Results: Statistically significant excess relative risks (ERR, %) in high-index compared with low-index (unexposed) municipalities were found for all-cause mortality (9.2 (95% CI 6.5 to 11.9) in men and 12.4 (9.5 to 15.4) in women and liver cancer (19.3 (1.4 to 40.3) in men and 29.1 (7.6 to 54.8) in women). Increased risks were also found for all cancer mortality (both sexes), stomach and lung cancer (in men). Statistically significant ERRs were found for CAs of the internal urogenital system (82.7 (25.6 to 155.7)) and of the central nervous system (83.5 (24.7 to 169.9)). Conclusion: Although the causal nature of the association is uncertain, findings support the hypothesis that waste-related environmental exposures in Campania produce increased risks of mortality and, to a lesser extent, CAs.

Cancer Mortality in an Area of Campania (Italy) Characterized by Multiple Toxic Dumping Sites

Abstract:  Several recent studies have documented that a widespread practice of dumping toxic wastes has taken place for many years in the Provinces of Naples and Caserta. Extensive programs of environmental monitoring are currently ongoing in the area. In this frame, the Department of Civil Defence of the Italian Government has appointed an ad hoc study group in order to assess the health status of the population resident in the area of interest. The first investigation performed by the study group has been a geographic study on cancer mortality and occurrence of malformations in 196 municipalities constituting the two Provinces. The study detected an area located in the southeastern part of the Province of Caserta and in the northwestern part of the Province of Naples, where cancer mortality and congenital malformations show significantly increased rates with respect to expected figures derived from the regional population. The area highlighted by the study is, in general terms, overlapping with the area where most illegal dumping of toxic wastes took place. It is now recommended that mortality studies be extended to take into account other health outcomes, to search for correlations with environmental exposures, and consider possible confounding factors.

Health impact assessment of waste management facilities in three European countries

BackgroundPolicies on waste disposal in Europe are heterogeneous and rapidly changing, with potential health implications that are largely unknown. We conducted a health impact assessment of landfilling and incineration in three European countries: Italy, Slovakia and England.MethodsA total of 49 (Italy), 2 (Slovakia), and 11 (England) incinerators were operating in 2001 while for landfills the figures were 619, 121 and 232, respectively. The study population consisted of residents living within 3 km of an incinerator and 2 km of a landfill. Excess risk estimates from epidemiological studies were used, combined with air pollution dispersion modelling for particulate matter (PM10) and nitrogen dioxide (NO2). For incinerators, we estimated attributable cancer incidence and years of life lost (YoLL), while for landfills we estimated attributable cases of congenital anomalies and low birth weight infants.ResultsAbout 1,000,000, 16,000, and 1,200,000 subjects lived close to incinerators in Italy, Slovakia and England, respectively. The additional contribution to NO2 levels within a 3 km radius was 0.23, 0.15, and 0.14 μg/m3, respectively. Lower values were found for PM10. Assuming that the incinerators continue to operate until 2020, we are moderately confident that the annual number of cancer cases due to exposure in 2001-2020 will reach 11, 0, and 7 in 2020 and then decline to 0 in the three countries in 2050. We are moderately confident that by 2050, the attributable impact on the 2001 cohort of residents will be 3,621 (Italy), 37 (Slovakia) and 3,966 (England) YoLL. The total exposed population to landfills was 1,350,000, 329,000, and 1,425,000 subjects, respectively. We are moderately confident that the annual additional cases of congenital anomalies up to 2030 will be approximately 2, 2, and 3 whereas there will be 42, 13, and 59 additional low-birth weight newborns, respectively.ConclusionsThe current health impacts of landfilling and incineration can be characterized as moderate when compared to other sources of environmental pollution, e.g. traffic or industrial emissions, that have an impact on public health. There are several uncertainties and critical assumptions in the assessment model, but it provides insight into the relative health impact attributable to waste management.

Ecological studies of cancer incidence in an area interested by dumping waste sites in Campania (Italy)

Cancer incidence was investigated in an area which has been affected by the illegal practices of dumping hazardous waste and setting fire to mismanaged waste. For the 35 municipalities of this area that are served by a Cancer Registry, municipal standardized incidence ratios (SIR) and hierarchical Bayesian estimators (BIR) were computed. Moreover, municipal spatial clustering and a Poisson regression by municipality index of waste-related exposure were performed for 10 cancer types. Increased municipality SIRs were found for some cancer types. The BIRs confirmed the increases for liver cancer in two municipalities. Statistically significant clusters were detected for liver, lung, leukaemia and soft tissue sarcomas. In the regression analysis, testis cancer showed significant trend with the index of waste-related exposure (RR = 1.18).

Industrial Activities in Sites at High Environmental Risk and Their Impact on the Health of the Population

Abstract A second mortality analysis of 15 areas of Italy identified in 1986 by the Italian Ministry of Environment as areas at high risk of environmental crisis has confirmed and extended the findings of the first. In regional comparisons, these areas, in which potentially hazardous industries are located, show excesses of deaths from almost all cancers and other diseases, particularly among men. Although more information is needed to identify corrective public health measures, the official recognition of areas in need of cleaning up, which appears to be unique to Italy and which fostered the study, is a promising beginning.

Growing inequalities in child injury deaths in Europe

In this short report, we describe and compare mortality data for injuries in children aged <15 years in the WHO European region as estimated by the WHO Global Health Estimates for 2000 and 2011. Child injury deaths have decreased overall. Mortality rate ratios between low- and middle-income countries (LMIC) and high-income countries in the region show an increase in relative inequalities for childhood deaths from unintentional injuries and a narrowing from intentional injury. This growing inequality in unintentional injury is a public health concern and calls for renewed efforts to reduce childhood injuries in LMIC the region.

Progress in preventing injuries: a content analysis of national policies in Europe

The aim of this paper is to provide a content analysis of national policies to address violence and injury prevention in the World Health Organization (WHO) European Region so as to inform where future improvements can be made. Multiple search methods were used to identify national policies for violence and injury prevention. Application of a framework based on a WHO guide was used for policy analysis. A multiple correspondence analysis (MCA) was additionally conducted. One hundred and twenty-three national policies were identified; of these, 80 were available in English language and analysed further. Most national policies had been developed after 2003. The majority of policies fulfilled most of the WHO criteria for effective policy-making. Policy areas requiring improvement include quantifying objectives, targeting the socio-economic gap in injury burden and increased focus on primary prevention. Results from the MCA confirmed the ones obtained with the descriptive statistics. Encouraging progress is being made in formulating national policy for violence and injury prevention within the WHO European Region. There are specific areas that warrant increasing attention in future policy development.

Progress in preventing injuries: an online inventory of national policies

Introduction As part of a 3-year collaborative project between WHO and the European Commission on progress achieved by Member States in implementing resolution EUR/RC55/R9 and the European Council Recommendation on the prevention of injuries, an inventory of national policies has been compiled by WHO Regional Office for Europe. Methods and results A web-based database was created using national policies for injury and violence prevention using an internet search in English or German. This was supplemented with a questionnaire survey completed by health ministry focal persons for injury and violence prevention. 97 policies from 30 countries were uploaded on the internet in 2008. These have been supplemented further in 2009 when an additional 72 national policies were identified. A content analysis of policies is being carried out to identify factors thought to be conducive to policy development and implementation. The documents in the inventory reflect policy initiatives undertaken at national level by different sectors such as health, justice, interior, social affairs and transport. Information can be viewed and searched on a country basis or as part of a regional overview and can be searched by type of injury or violence, target group and lead sector. Conclusions This inventory of national policies for injury and violence prevention is a resource for policy-makers and practitioners interested in seeking more information. It represents a user-friendly system that can be used as a baseline to map future progress, to advocate for greater commitment and action, and to facilitate the sharing of information.

Implementation of evidence-based interventions to prevent drowning: results from a WHO collaborative project

Introduction 34 000 drowning-related deaths are observed yearly in WHO European Region. Rates in low- and middle-income countries are six times higher than in high-income countries. Methods A questionnaire survey was undertaken as part of a collaborative project between WHO and the European Commission on progress achieved by Member States in implementing the WHO resolution and the European Council Recommendation on the prevention of injuries. Information was used on the implementation of eight evidence-based interventions to prevent drowning. Countries were grouped according to geographical location. Mortalities for drowning were examined by country grouping and correlated with level of implementation of interventions at a subregional level. Results There were responses from 47 of the 51 Member States with focal persons. Regional median implementation of drowning prevention interventions was 63% (IQR: 38–75%). The average mortality for the Baltic countries is six times higher than that for Nordic countries for both sexes. Implementation was variable across groups: 81% in Nordic countries, 73% in southern countries, 70% in CIS, around 50% in western, central and southeastern countries, only 8% in the three Baltic countries. In particular, no interventions were implemented in Lithuania and Latvia, only 25% in Estonia. Conclusions An inverse correlation can be observed between the implementation of evidence-based interventions and mortality for drowning in European countries when subregions are considered. The health sector needs to take a leadership role in advocating for the widespread implementation of effective programmes and to engage with other stakeholders in a multisectoral response to prevent drowning.