Environment and health risks: of social inequalities Environment and health risks: a review of the influence and effects of social inequalities ABSTRACT This report serves as a background document for the policy brief on social and gender inequalities in environment and health that was prepared for the Fifth Ministerial Conference on Environment and Health (Parma, Italy, 10–12 March 2010). It provides an overview of the currently available evidence on the influences and effects of social and gender inequalities on environmental health risks. The evidence has been compiled for six environmental health challenges (air quality, housing and residential location, unintentional injuries in children, work-related health risks, waste management and climate change) as well as for gender-related inequalities and children’s exposure. Additional chapters present interventions on child-related environmental inequalities and social inequalities in environmental health risks in the Russian Federation. Although the evidence base on social inequalities and environmental risk is fragmented and data are often available for few countries only, it indicates that inequalities are a major challenge for environmental health policies. The review confirms that people living in adverse socioeconomic conditions in Europe can suffer twice as much from multiple and cumulative environmental exposures as their wealthier neighbours, or even more. Similarly, inequalities in exposure to environmental threats have been identified for vulnerable groups such as children and elderly people, low-education households, unemployed persons, and migrants and ethnic groups. Only little evidence is available indicating that in some circumstances, well-off and advantaged social groups are more at risk. Irrespective of developmental status, environmental inequalities can be found in any country for which data are available. Despite lack of data from many Member States of the WHO European Region, social inequalities in environmental risk must therefore be considered a public health issue for each country and the whole Region. Keywords ENVIRONMENTAL HEALTH ENVIRONMENTAL EXPOSURE SOCIOECONOMIC FACTORS RISK FACTORS GENDER IDENTITY EUROPE Address requests about publications of the WHO Regional Office for Europe to: Publications WHO Regional Office for Europe Scherfigsvej 8 DK-2100 Copenhagen Ø, Denmark Alternatively, complete an online request form for documentation, health information, or for permission to quote or translate, on the Regional Office web site (http://www.euro.who.int/pubrequest). © World Health Organization 2010 All rights reserved. The Regional Office for Europe of the World Health Organization welcomes requests for permission to reproduce or translate its publications, in part or in full. 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 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. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products 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. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either express or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. The views expressed by authors, editors, or expert groups do not necessarily represent the decisions or the stated policy of the World Health Organization . page iii CONTENTS Page Acknowledgements iv Introduction 1 1. Social inequalities in health risk related to ambient air quality 5 2. Social inequalities in environmental risks associated with housing and residential location 33 3. The social inequalities in health risks related to unintentional injuries among children 76 4. Social inequities in working environment and work-related health risks 105 5. Inequalities, inequities, environmental justice in waste management and health 127 6. Social inequalities in environmental risks associated with global climate change 149 7. Environmental inequalities among children and adolescents. A review of the evidence and its policy implications in Europe 159 8. Summary report on interventions and actions to tackle inequities in physical activity in children 199 9. Abstracts of country case studies on interventions a nd actions to tackle inequities in physical activity in children 205 10. Gender inequities in enviro nment and health 217 11. Social inequality and environmental health in the R ussian Federation 238 page iv Acknowledgements This evidence review has been compiled by the WHO European Centre for Environment and Health (Bonn Office) and is based on three expert meetings on social inequalities and environmental risks organized in preparation to the Fifth Ministerial Conference on Environment and Health (Parma, Italy, 10–12 March 2010):  WHO meeting on “Environment and health risks: the influence and effects of social inequalities”, Bonn, Germany, 9–10 September 2009, supported by funds from the Federal Ministry of the Environment, Germany;  “Socio-environmentally determined health inequities among children and adolescents. WHO/Health Behaviour in School-Aged Children (HBSC) Forum”, Siena, Italy, 19–20 October 2009, supported by funds from the Tuscany Region, Italy and the National Health Service (NHS) Scotland;  “Gender inequalities in environment and health”, Madrid, Spain, 11–12 November 2009, organized and funded by the Observatory of Women's Health of the Ministry of Health and Social Policy of Spain. WHO is grateful for the contributions of the authors of the individual chapters as well as the comments made by participants at these meetings. page 1 Introduction Social determinants of health have a strong influence on a wide diversity of health endpoints. The same is valid for the field of environmental health, as the exposure to environmental risk factors is also unequally distributed, and this unequal distribution is often related to social characteristics such as income, social status, employment and education, but also non-economic aspects such as gender, age or ethnicity. However, depending on the environmental risk and the “risk group” considered, the magnitude of inequality varies largely. The realization of the social pattern in risk exposure has resulted in the adoption of methodologies to formally take into account these effects. Typically, the health risks depending on socioeconomic factors have a strong potential for acting as confounders of the parameter of interest, i.e. the association between health and the respective risk factor. Standardization techniques are applied to remove their contribution and assess the risk factor-health association independent of the influence of socioeconomic factors. This practice has greatly contributed to better assessment of various environmental risks, and is nowadays firmly established in environmental epidemiology. However, this also reflects the strong expectation that socioeconomic factors are associated to environmental exposures. Still, complete understanding of how environmental risk factors operate in the reality of the social environment has not been reached, and would be very informative especially for designing effective policy responses. As a first step towards better understanding of the impact of social inequalities on the distribution of environmental risks, this report presents a compilation of European evidence on the impact of social determinants on environmental risk. This report mainly draws from contributions to a background document for the WHO expert meeting on “Environment and Health risks: the influence and effects of social inequalities” funded by the Federal Ministry of the Environment, Germany (Bonn, 9–10 September 2009). 1 It incorporates additional contributions from expert meetings on social inequalities and environmental risks which were supported by funds from the Tuscany Region, Italy and the National Health Service Scotland (“Socio-environmentally determined health inequities among children and adolescents. WHO/Health Behaviour in School-Aged Children (HBSC) Forum”, Siena, Italy, 19–20 October 2009) 2 and the Ministry of Health of Spain (“Gender inequalities in environment and health”, Madrid, Spain, 11– 12 November 2009). 3 This review report focuses on evidence from the Member States of the WHO European Region but also recognizes key evidence from outside Europe helpful to understand the associations between social factors and environmental risk exposure. It aims at contributing towards an evidence base for addressing environmental inequalities and is one of the documents made available to the participants of the Fifth Ministerial Conference on Environment and Health (10–12 March 2010 Parma, Italy). Specifically, 1 Further information and meeting report available from the WHO Regional Office for Europe (http://www.euro.who.int/envhealth/topics/20090706_2). 2 Further information available from the WHO Regional Office for Europe (http://www.euro.who.int/childhealthenv/0090514_1). 3 Further information and meeting report available from the WHO Regional Office for Europe (www.euro.who.int/gender). page 2 it gives the scientific background details for the Ministerial Conference policy brief on social and gender inequalities in environment and health. 4 For the preparation of the individual reports, authors were provided with a suggested framework model developed by WHO 5 to structure and decomposite the potential pathways through which social determinants and inequities could possibly affect the chain that leads from environmental conditions through environmental risk exposure and the exposure-response function to the health outcomes. The framework model (Fig. 1) suggests four major pathways: • arrow 1: social determinants affect the environmental conditions of an individual and may contribute to the fact that specific individuals or population groups more often experience less adequate or potentially harmful environmental conditions. • arrow 2: social determinants may directly affect exposure beyond and in addition to the exposure that is related to arrow 1 (within same environmental conditions, the “affected” population groups could still be more exposed through e.g. the mechanism of education and health behaviour). • arrow 3: given the same exposure, (socially) disadvantaged groups could show more severe health effects if the social disadvantage is associated with some mechanism that modifies the effects and therefore influences the exposure- response function. • arrow 4: sufficient evidence is available that social determinants affect health (what remains unclear is the relative importance of socially determined exposure to environmental risk factors). Arrows 1 and 2 are representing the “exposure differential” – indicating the variation of exposure – and arrow 3 represents the “vulnerability differential,” indicating the variability of the exposure-response function and – therefore – the vulnerability of individuals. Both differentials together would expect to explain the degree of environmental inequalities identified. Next to the processes causing the unequal distribution of environmental risks and outcomes, the framework model identifies the institutional landscape and the respective services and actions to tackle inequalities. A variety of actors is called upon to reduce and mitigate the occurrence of environmental inequalities, be they socially determined or not. In first place, responsibility is with the environmental actors and stakeholders shaping the environmental conditions, such as actors on environment, transport, housing, occupational settings etc. However, the health sector has also a key role to play which is not reduced to the provision of care services, but also includes preventive action and environmental health services which in most cases must be based on collaboration with other sectors, shaping a common health-in-all policies approach (HIAP). Clearly, national health and welfare systems need to address the increasing problem of health inequalities, and as environmental inequalities are a major contributor to health inequalities, it is necessary to join forces with other sectors. 4 Further information and policy brief on environmental and gender inequalities available from the WHO Regional Office for Europe (http://www.euro.who.int/parma2010/docs/20100201_1). 5 WHO (2009). Socioeconomic inequities – scenarios, recommendations and tools for action. Copenhagen, WHO Regional Office for Europe, 2009 (http://www.euro.who.int/document/eehc/29th_eehc__bonn_edoc15.pdf). page 3 Fig. 1. The WHO framework model on social inequalities and environmental risks This document is structured into three categories. First, six evidence reviews on the impact of social determinants on environmental risk are presented, making the case for different environmental inequalities, and different risk groups. The first chapter, provided by Deguen (France) and Zmirou-Navier (France), deals with the inequalities in air pollution, focusing on ambient air. The second chapter by Fairburn (United Kingdom) and Braubach (WHO) addresses inequalities in the field of housing and residential location, including indoor environmental conditions as well as neighbourhood and residential effects. The third chapter, written by Laflamme (Sweden), Hasselberg (Sweden) and Burrows (Canada), presents the available evidence of the social divide in child injuries based on a larger WHO review project published in early 2009. The fourth chapter on inequalities related to occupational conditions is written by Brenner (United States) and reviews the relationship between social status and working conditions, followed by chapter five by Martuzzi (WHO), Mitis (WHO) and Forastiere (Italy) on inequalities related to waste management. Chapter 6 by Kovats (United Kingdom), Wilkinson (United Kingdom) and Menne (WHO) reviews the impacts of climate change on environmental inequalities and takes on a more forward-looking perspective. Second, evidence reviews are presented to assess the dimension of socially triggered environmental inequalities for specific risk groups. Chapters 7–9 holistically address environmental inequalities in children and consist of an evidence review contributed Environmental conditions Exposure Health effects and costs Exposure– response function Stakeholders and HiAP actors (environment, housing, transport, social, etc.) Public, health and social services/ health system 1 2 3 4 Individual susceptibility Access to/quality of health services Environmental p rotection Preventive environmental and health services Health p rotection/education Effect modifiers Driving forces Macroeconomic context: increasing social disparities and stratification Inequalities of socioeconomic conditions/social determinants (income, education, occupation, migrant status, gender, etc.) page 4 by Bolte (Germany), Kohlhuber (Germany), Carpenter (United States) and Tamburlini (Italy), followed by contributions from the WHO/HBSC network on interventions and actions to tackle inequities in physical activity in children (contributed by Pattison (United Kingdom (Scotland)) and Nemer (WHO)) and the abstracts of country case studies on lessons learned with physical activity-promoting interventions for children. The gender perspective and its reflection in environmental inequalities is described by Cantarero (Spain) and Yordi (WHO) in Chapter 10. Third and finally, Chapter 11 presents a country profile on social inequality and environmental health in the Russian Federation (contributed by Boris Revich, Russian Federation) as an indication of the potential expression of environmental inequalities in Russian-speaking countries for which very little evidence seems currently available in international literature. page 5 1. Social inequalities in health risk related to ambient air quality Authors Séverine Deguen EHESP School of Public Health France Denis Zmirou-Navier EHESP School of Public Health INSERM U954 Vandœuvre-les-Nancy Nancy University Medical School France Abstract Background Evidence of social inequalities in health is now well established in most developed countries. Environmental nuisances, including ambient air pollution, are thought to contribute to such equalities. In spite of improvements in air quality over the last decades in developed countries, air pollution remains a major investigation field and action domain for improving public health. It may still represent a strong factor of health inequalities. There are two major mechanisms, which may act independently or synergistically, through which air pollution may play this role. Disadvantaged groups are recognized as being more often exposed to air pollution (differential exposure); they may also be more susceptible to the resultant health effects (differential susceptibility). Review methods/data Research articles were obtained through a literature search in the Medline database of the National Library of Medicine. We selected articles as of the end of April 2009; the more recent articles were privileged. The main keywords used to perform this literature review are “Socioeconomic Factors AND Air Pollution” AND “Health”; numerous synonymous expressions of these three keywords have been also used. This chapter will pay special attention to European studies and to children considered as a more “vulnerable” subgroup. Results Some European studies found that poorer people were more exposed to air pollution whereas the reverse was observed in other papers. A general pattern, however, is that, irrespective of exposure, subjects of low socioeconomic status experience greater health effects of air pollution. Several suggested pathways and mechanisms have been identified. Housing market dynamic bias in land use decisions could explain why several populations cumulate poor socioeconomic status and poor air pollution exposure. 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Environment and health risks: of social inequalities Environment and health risks: a review of the influence and effects of social inequalities ABSTRACT. inequalities in environmental health risks in the Russian Federation. Although the evidence base on social inequalities and environmental risk is fragmented and data are often available for few. management and health 127 6. Social inequalities in environmental risks associated with global climate change 149 7. Environmental inequalities among children and adolescents. A review of