ENVIRONMENT AND HEALTH Public Disclosure Authorized IN CENTRAL AND EASTERN EUROPE Public Disclosure Authorized ~- -t -- w w Public Disclosure Authorized CLYDE HI3RTZMAN Public Disclosure Authorized A REPORT FOP, THE ENVIRONMENTAL ACTION PROGRAMME FOR, CENTRAL AND EASTERN EUROPE ENVIRONMENT AND HEALTH IN CENTRAL AND EASTERN EUROPE CLYDE HERTZMAN WITH CONTRIBUTIONS BY ZOLTAN ANNAU, WENDY AYRES, GORDON HUGHES. MICHAL KRZYZANOWSKI, AND BARRY LEVY A REPORT FOR THE ENVIRONMENTAL ACTION PROGRAMME FOR CENTRAL AND EASTERN EUROPE THE WORLD BANK WASHINGTON. D.C. (© 1995 The International Bank for Reconstruction and Development/The World Bank 1818 H Street, N.W., Washington, D.C. 20433, U.S.A. All rights reserved Manufactured in the United States of America First printing August 1995 The findings, interpretations, and conclusion expressed in this publication are those of the authors and do not necessarily represent the views and policies of the World bank or its Board of Executive Directors or the countries they represent. Some sources cited in this paper may be informal documents that are not readily available. The material in this publication is copyrighted. Requests for permission to reproduce portions of it should be sent to the Office of the Publisher at the address shown in the copyright notice above. The World Bank encourages dissemination of its work and will normally give permission promptly and, when the reproduction is for noncommercial purposes, without asking a fee. Permission to copy por- tions for classroom use is granted through the Copyright Clearance Center, Inc., Suite 910, 222 Rosewood Drive, Danvers, Massachusetts 01923, U.S.A. The complete backlist of publications from the World Bank is shown in the annual Index of Publications, which contains an alphabetical title list (with full ordering information) and indexes of subjects, authors, and countries and regions. The latest edition is available free of charge from Distribution Unit, Office of the Publisher, The World Bank, 1818 H Street, N.W., Washington, D.C. 20433, U.S.A., or from Publications, The World Bank, 66, avenue d'Iena, 75116 Paris, France. The boundaries, colors, denominations, and other information shown on any map in this volume do not imply on the part of the World Bank Group any judgement on the legal status of any territory or the endorsement or acceptance of such boundaries. Library of Congress Cataloging-in-Publication Data Hertzman, Clyde, 1953- Environment and health in central and eastern Europe: a report for the Environmental Action Programme for Central and Eastern Europe / Clyde Hertzman. p. cm. Includes bibliographical references (p. ). ISBN 0-8213-3173-6 1. Environmental health-Europe, Central. 2. Environmental health-Europe, Eastern. 3. Pollution-Europe, Central. 4. Population-Europe, Eastern. I. Title. RA566.5.E853H47 1995 615,9'02'0947-dc2O 94-48510 CIP Table of Contents Preface vii Executive Summary ix Introduction I The Determinants of Health in Central and Eastern Europe 2 The evolution of the East-West life expectancy gap 2 A new approach to analyzing the life expectancy gap 3 Coniceptual and accounting framework 3 Competing explanations for the current life expectancy gap 5 The historical long wave 5 The contribution of the chemical and physical environment 5 Health care and the economy 9 The contribution of individual lifestyle factors 10 The contribution of the social, political, and economic environment 11 A reappraisal of the determinants of health in Central and Eastern Europe 15 Health and Environmental Pollution 16 Methods of data evaluation 17 The geography of environmental health conditions in the region 19 A regional hot spot-the mining districts of Northern Bohemia, Czech Republic 19 A town at the confluence of point sources of pullution-Copsa Mica, Romania 19 "Bad town planning"-Dimitrovgrad, Bulgaria 19 Health problems associated with the principal environmental exposures in the region 20 Exposure to lead 20 Respiratory conditions and other problems associated with air pollution 25 Other environmental health problems in the region 42 Arsenic in drinking water 42 Infectious disease and microbiologically contaminated water 43 Problems unique to specific locations 46 Environmental conditions of special concern to human health, but for which no health data exist 48 Contaminants in food 49 Human Health and the Environmental Action Programme for Central and Eastern Europe 51 Economic transformation and environmental health 52 Priority investments and health 53 This report was prepared for the World Bank by Clyde Hertzman. The report also incorporates contributions by Zoltan Annau, Wendy Ayres, Gordon Hughes, Michal Krzyzanowski, and Barry Levv.The editor was Wendy Ayres. The work was carried out under the general direction of Richard Ackermann. Clyde Hertzman is an Associate Professor in the Department of Health Care and Epidemiology,Faculty of Medicine at the University of British Columbia. He is also a Fellow of the Programs in Population Health and Human Development in the Canadian Institute for Advanced Research. iii Other strategic considerations 56 The need for remediation-oriented health data 57 Annexes 59 I Separating fact from fiction: collecting and evaluating environmental health information 61 2 Temporal trends in life expectancy 69 3 Temporal trends in infant mortality 71 4 Summary of human health problems and major industrial plants located in pollution "hot-spots" in Bulgaria, Czech and Slovak Republics, Hungary, Poland, Romania, Latvia, Lithuania, Estonia, Belarus, Ukraine, and European Russia 73 5 Heavy metal contamination: selected data 91 6 Ambient air and water quality: selected data 93 7 Health status in relation to environmental pollution: selected data 99 8 PCB food contamination in the Slovak Republic 101 9 Places where more information is needed 103 10 Occupational health 105 Bibliography 113 Boxes 3.1 Chernobyl 37 3.2 Environment and health in Russia 44 4.1 Airborne dust or gases-which is more important? 52 4.2 Environmental improvements in the non-ferrous metals industry-Plovdiv and Copsa Mica 54 4.3 Cost-effective ways to control emissions from transportation sources 55 4.4 Environmental investments in the iron and steel industry 55 4.5 Investments to control emissions from coal burning 56 Text Tables 2.1 The emerging gap in life expectancy after age thirty 3 2.2 Historical evolution of life expectancy in Finland and Latvia 7 2.3 Evolution of life expectancy in the Czech and Slovak Republics by province 7 2.4 Relative risks of neonatal problems in districts of the Czech Republic ranked by air pollution 8 2.5 Historic changes in average annual sulfur dioxide concentrations 8 2.6 Medically avoidable death rates 10 2.7 Temporal trends in age-specific cardiovascular mortality rates 12 2.8 Infant mortality rates in Poland in relation to mother's maximum level of education attained, 1987 12 2.9 Age-specific death rates (per 100,000)by level of education in the Czech Republic, 1979-1982 13 3.1 Metal content of materials used for liming soils in Poland 20 3.2 Allotment gardens near point sources of metals, Poland 21 3.3 Daily metal intake from food in Polish adolescents, 1983 21 3.4 Soil lead levels in three contaminated areas in Katowice 21 3.5 Blood lead in children and mothers in various places within the Katowice region, 1989 22 3.6 Blood lead levels among children in Zabrze, Katowice 22 3.7 I.Q.s of children with different blood lead levels, Katowice 22 3.8 Blood lead levels among children in Hungary 23 3.9 Children's blood lead levels in the area of Plovdiv and Asenovgrad, Bulgaria 24 3.10 Sulfur dioxide levels in OECD and Polish cities 25 3.11 Historic changes in average annual sulfur dioxide concentrations in the Czech and Slovak Republics 26 3.12 Sulfur dioxide concentrations and respiratory disease in Poland, 1979-82 28 3.13 Incidence of congenital anomalies, Usti nad Labem, 1972-81 29 3.14 Prevalence of respiratory conditions in Devnya, Bulgaria 31 3.15 Pulmonary function among children in Dimitrovgrad, Bulgaria 31 3.16 Classification of children's developmental status in Dimitrovgrad, Bulgaria 32 3.17 Mortality in Saka compared with Estonia as a whole, 1979-88 35 3.18 Districts with concordant high male-female site specific cancer rates, Bulgaria, 1985-87 36 3.19 Standardized incidence ratios for cancer in the Czech Republic 39 3.20 Maximum measured nitrate levels, Belarus, 1987-90 42 iv 3.21 Water supplies not meeting microbiological and chemical standards, Lithuania 46 3.22 Mutagenic urine among children in Katowice Province, 1987 48 3.23 Mutagenic activity of chemical pollutants in the ambient air, Ukraine 50 3.24 Food quality in Lithuania 50 Text Figures 2.1 Model for investigating heterogeneities in population health status 4 3.1 Effect of nature school on respiratory, immune, and hematological parameters among 36 children from polluted parts of central Bohemia 30 3.2 Incidence of digestive tract cancers in relation to nitrate in drinking water in seven areas of Borsod County, Hungary 35 3.3 Mortality by mining and non-mining districts of northern Bohemia, 1983-87 40 Text Maps 3.1 Districts of the former Czechoslovakia by the percentage of residents living in areas with the highest levels of air pollution 38 3.2 Female life expectancy by district, 1981-85 39 Annex Tables A4.1 Major industrial plants located in pollution "hot-spots" 77 A5.1 Lead and cadmium in potatoes in selected localities in Poland 91 A5.2 Lead and cadmium in garden plots in Katowice 91 A5.3 Metal contamination