Marco Martuzzi

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.

Increasing incidence of childhood leukemia in Northwest Italy, 1975-98.

Although some childhood cancer registries reported increasing incidence, the evidence and magnitude of time trends in the incidence of childhood leukemia are debated and the scientific evidence is conflicting. Only limited data have so far been supplied from Southern European countries. We present an analysis of the incidence trend of childhood leukemia in Piedmont (NW Italy) in 1975–98, based on data from the population‐based childhood cancer registry. The Childhood Cancer Registry of Piedmont has been recording cases of childhood neoplasms since 1967. Procedures have been uniform and are based on an active search for cases and relevant information. Only cases with confirmed residence in Piedmont at diagnosis are included. Eight hundred cases of leukemia (622 acute lymphoblastic [ALL], 133 acute nonlymphoblastic [AnLL], 45 other and unspecified) were recorded in the period 1975–98 considered in our study. Incidence trends were analyzed using piecewise regression and Poisson regression, based on annual incidence rates. As results from the 2 analyses were similar, only the former were reported. In the age group 1–4 years, a statistically significant annual 2.6% increase in incidence rate of ALL (adjusted by age and gender; 95% confidence interval [CI] 1.13–4.13) was estimated. There was no evidence of increase in other age groups. During 1980–98, a statistically significant 4.4% annual increase (95% CI 1.86–6.90) was seen for pre‐B‐All in the age group 1–4 years. An increase was also seen for T‐ALL that was not statistically significant. Sensitivity analyses were conducted, with no relevant differences from the main results. Our data suggest an increasing trend in ALL incidence for children between the ages of 1 and 4 years. These results are unlikely to be explained by changes in quality of data or exhaustiveness in reporting in the study period. The results were not changed in the sensitivity analyses we conducted. Possible causes to be investigated include environmental factors, changes in family size and parental age, socioeconomic conditions and geographical distribution of cases.

Declining Trends of Male Proportion at Birth in Europe

Abstract Declining trends in male proportion at birth observed in several Western countries might reflect widespread exposure to pollutants capable of interfering with human reproduction. In this study, the authors describe male live birth proportion trends in 23 European countries from 1950 to 1996 (total of 305 million live births). Overall, there was a significant linearly decreasing trend of 10 fewer males per 100,000 births each year, resulting in a loss of 73,462 boys during a 47-yr period. The proportion of male births during the first 3 yr of the study period was higher than in the last 3 yr in 18 countries (i.e., 78%). Decreasing trends, which varied in slope and shape, were observed in 11 countries; no significant trend was found in 8 countries, and male birth proportion increased in 4 countries. The results of this study confirmed that the proportion of male births is declining in Europe, and differences exist by region and country. Social and cultural aggregations of countries with decreasing trends suggest that sociodemographic characteristics might be more likely to explain trends than environmental exposures to chemicals. Investigators should evaluate this hypothesis to assess the usefulness of male birth proportion as a sentinel event.

Health impact assessment of agriculture and food policies: lessons learnt from the Republic of Slovenia

The most important public health priority in agricultural policy-making is currently food safety, despite the relatively higher importance of food security, nutrition, and other agricultural-related health issues in terms of global burden of disease. There is limited experience worldwide of using health impact assessment (HIA) during the development of agriculture and food policies, which perhaps reflects the complex nature of this policy sector. This paper presents methods of HIA used in the Republic of Slovenia, which is conducting a HIA of proposed agricultural and food policies due to its accession to the European Union. It is the first time that any government has attempted to assess the health effects of agricultural policy at a national level. The HIA has basically followed a six-stage process: policy analysis; rapid appraisal workshops with stakeholders from a range of backgrounds; review of research evidence relevant to the agricultural policy; analysis of Slovenian data for key health-related indicators; a report on the findings to a key cross-government group; and evaluation. The experience in Slovenia shows that the HIA process has been a useful mechanism for raising broader public health issues on the agricultural policy agenda, and it has already had positive results for policy formation. HIA is one useful approach to more integrated policy-making across sectors, but clearly it is not the only mechanism to achieve this. A comparison of the approach used in Slovenia with HIA methods in other countries and policy contexts shows that there are still many limitations with HIA application at a government level. Lessons can be learnt from these case studies for future development and application of HIA that is more relevant to policy-makers, and assists them in making more healthy policy choices.

EMPIRICAL BAYES ESTIMATION OF SMALL AREA PREVALENCE OF NON-RARE CONDITIONS

Geographical studies are becoming increasingly common in epidemiology. The problems of small area investigations are well known, and several methods are available for the estimation and mapping of disease risk across small areas, with the emphasis mainly on applications concerning rare disease incidence or mortality. An empirical Bayes method is proposed for small area estimation of the prevalence of non-rare conditions, whose variability is binomial and cannot be approximated by a Poisson model. It is the direct equivalent of a semi-parametric non-iterative moment estimation method proposed in the Poisson case. As an example, the geographical distribution of the prevalence of respiratory symptoms in schoolchildren across 71 small areas in Huddersfield, Northern England is studied. Whereas random variability causes the crude area-specific prevalences to be unstable, the posterior estimates, corrected towards overall or local means, are capable of highlighting genuine extra-binomial variability. The method is very simple and can readily be applied to the study of a number of common conditions.

The precautionary principle: in action for public health

Better health, better environment, better science: better use the precautionary principle Article 174 of the Amsterdam Treaty of the European Union says “Community policy on the environment […] shall be based on the precautionary principle”. European law, at its highest level, is explicit and uncompromising. As promotion and protection of human health is one of the key motivations of environmental preservation, the provision of the Treaty is good news for public health too. In fact the importance and relevance of the precautionary principle in the health domain has been attracting growing interest.1 Ministers of health, together with ministers of environment of the Member States in the World Health Organization (WHO) European Region (52 of them in 2004) declared: “We reaffirm the importance of the precautionary principle as a risk management tool, and we therefore recommend that it should be applied […]”.2 These are only two of many acts or laws where the precautionary principle is referred to. So what is this principle and why is it important for public health as well as the environment? Born in the environmental domain in the 1970s, the precautionary principle gained political profile in the 1980s and 1990s, and has attracted the attention of many involved in matters of environmental protection.3 Despite its resonance, there is no unanimously agreed definition of the principle. Quite simply, it is usually taken to state that lack of scientific certainty must not be used as a reason to ignore or postpone preventive or remedial action when there are other good reasons to do so, as has happened many times in the past.4 The prescription to err on the side of caution, the “better safe than sorry” approach, may …

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).