SYNTHESIS OF THE MAIN FINDINGS OF THE REPORT

The significant increase in life expectancy clearly indicates that health status has improved in the EU in the last decades, in spite of the smaller increases recorded in the Eastern European Member States. Main reasons for this improvement are the more effective control of infectious diseases and a reduced mortality attributed to cardio-vascular and respiratory diseases since the 70's and of most cancer types (but not lung cancer) in the 90's. Increased life expectancy, together with the increased use of birth control, has resulted in the ageing of populations of all EU Member States. This trend has considerably increased the number of retired persons, who, in principle, have a lower income. Taking into account that the elderly are more susceptible than the young to a variety of diseases and health problems, it is not surprising that the increase in life expectancy does not result in an increase in the life years spent in good health. This is the case for women, who, despite their higher longevity, by about six years with respect to men, live in good health only two years more than men.

As for the health status of different age groups of the population, it can be concluded, although the health monitoring system is mainly focused on adults, that newborns are healthier than in the past. Infant mortality is steadily decreasing and low birth-weight (less than 2500 g) is still an important health indicator. The health status of children and adolescents (aged up to 18) in respect of chronic diseases with early onset, disabilities, special education needs, abuse and non-fatal injuries remains mostly unknown. However, indications of improved health conditions of children and adolescents are evident with reference to HIV/AIDS, accidents and injuries, while metabolic syndrome, overweight and obesity are becoming more common among adolescents.

The main causes of death in people of working age (less than 65) are cardio-vascular diseases, cancer, injuries and poisoning. Moreover, between 15 and 20% of adults have suffered from brain diseases or mental disorders, Four of the six leading causes of years lived with disability are due to neuropsychiatric disorders. The most common forms of mental ill health in the EU are anxiety disorders and depression. The percent of people with diabetes is increasing. Overweight and obesity cause about one million deaths each year in the WHO European Region. The high rates of mortality observed in the Eastern EU Member States, are mainly due to high mortality in male adults, caused by non-communicable diseases and accidents.

Elderly people suffer more often than the young from multiple diseases associated with disability. Depression, which affects 10-15% of people over 65, is the main cause of suicide in the elderly population. Accidents, mostly due to falls, are very frequent in this population age bracket.

As for male-female gender differences, mortality rates are similar up to the age of 15, while, between 15 and 65 years of age, men have a mortality rate much higher than women for all the main causes of death, being around four times higher for transport accidents. If gender-specific cancers are excluded, men develop cancer earlier and show lower survival. Similar considerations hold for cardiovascular diseases. Moreover, one in three women and one in eight men aged 50 or more are affected by enhanced bone fragility and an increased fracture risk. The health of women at delivery is improving and maternal mortality is decreasing considerably. Moreover, there is a trend to late delivery and to higher frequency of caesarean sections in all Member States, while the use of in vitro fertilization techniques shows large differences among the EU Member States. Women experience risky sexual intercourse and other episodes of physical, sexual and psychological violence more often than men.

The individual health status is dependent on different types of determinants, either endogenous or exogenous. Among the former, very important determinants are the human individual characteristics, encompassing genetic factors (e.g. in the case of diabetes), developmental factors (e.g. disturbances of the neuronal development during fetal life, the effects of placental dysfunction, gestational diabetes and smoking of during pregnancy), age, and other physiological characteristics. Individual behaviour is also important and seven main lifestyles have been identified which are capable of affecting health and inducing diseases.

• Direct tobacco smoking is a risk factor for six of the eight main causes of death worldwide, including cardiovascular disease, cancer and chronic obstructive pulmonary disease. A significant impact on health has also been attributed to passive smoking. Due to the recent increase of smoking among girls, there is currently a minor difference in the smoking habits between boys and girls: 20% smokers among boys and 16% among girls. Moreover, Europe shows the highest incidence in the world of smokers aged 13-15, that is 18%, twice as much as the world average.

• Health problems associated with alcohol drinking (mostly neuropsychiatric conditions and accidents) affect about 42 million people in Europe, and many others suffer because of those who drink. Binge drinking has become more common especially among youths, but also among adults.

• As for the misuse of illicit substances, the current European situation features a fall in the number of people seeking treatment for opioid use and an increase in those seeking treatment for cannabis and cocaine. An increased prevalence in the use of cocaine use been recorded among young adults (aged 15-34) in all countries where data is available. A substantial proportion of injecting drug users are still infected by hepatitis C virus; in fact about one million people are infected by this virus.

• In several Member States an increasing prevalence of risky sexual behaviour, such as those with occasional partners without use of a condom. In central and western Europe about 15000 people are infected each year by HIV/AIDS and in several Countries there is an increasing trend of Chlamydia infections, as well as persistence of gonorrhoea and syphilis.

• As for dietary habits, surveys of food consumption and epidemiological investigations on overweight and obesity depict a very worrying situation. In 1999 in the EU-15 food consumption resulted in the ingestion of 300 kcalories per person per day more than in 1970, while the rate of obesity and overweight are especially alarming among children and adolescents. In spite of the excessive food intake, a number of pathological conditions are observed in association with specific nutrient deficiency: this is the case for neural tube defects (associated with the peri-conceptional deficiency of folate), goitre, (due to iodine deficiency), anaemia (associated with iron deficiency) and osteoporosis (in association with calcium deficiency).

• The conditions caused by dietary imbalance observed in the EU are aggravated by physical inactivity. In the EU, one citizen in three takes no physical exercise during leisure time and two in three adults do not reach recommended levels of physical activity.

• Oral hygiene is characterized by the increased habit of tooth-brushing twice a day with fluoride-containing toothpaste, which is strongly associated with the decline of caries prevalence and severity and of gingival bleeding.

Physical, biological and chemical agents, to which individuals are exposed, also concurrently, through different ways, make up another group of important health determinants. The health impact of environmental causes is much higher in the Eastern than in the Western EU. Carcinogenic agents, such as radon and ultraviolet radiation, and noise, which is associated with irritability and other health effects caused by sleep loss, are among the physical agents with the highest impact on health. About 40% of the European population is exposed to levels of road traffic noise higher than 55dB and in most Member States, 10% population or more suffer from an exposure to noise levels higher than 65dB. New studies confirm that climate changes take place more and more rapidly. The hottest ten years recorded since the beginning of systematic monitoring of environmental temperature have occurred after 1990 and the current levels of methane and carbon dioxide, the so called green-house gases, are much higher than in the past. In recent years the European States have experienced more frequent and severe extreme atmospheric events such as heat and cold waves, floods, droughts, fires and intense rainfalls, which put many people at risk of death and injuries.

The production of toxic and high risk chemicals has increased steadily. Humans are exposed to these substances as shown by the presence, in the body of any EU citizen, of xenobiotic chemicals. Atmospheric pollution, especially if associated with fine particles is the environmental factor responsible for the heaviest health impact in terms of diseases related to the living and working environment. In several EU cities, about 90% of the population is exposed to atmospheric pollution levels exceeding the maximum levels set by the WHO guidelines. Recent estimates indicate that about 20 million citizens every day suffer from respiratory symptoms associated with pollution caused by urban traffic and heating plants. The European SCALE project, focusing on children, identified four priority groups of diseases associated with environmental chemical contaminants: childhood cancers, childhood respiratory health/asthma and neuro-developmental and endocrine disorders.

Biological agents include pathogenic viruses, fungi and recently discovered agents such as prions. Some of these agents may pose a severe threat to human health, especially in association with the development of strains resistant to antimicrobials. This is the case of methicillin-resistant S. aureus (MRSA), which is more and more associated with invasive infections. Resistance to antimicrobials is especially critical when developed by agents responsible for global killer diseases, such as tuberculosis, malaria and pneumococcal infections. Another issue of high concern to public health is connected with the selection of highly pathogenic virus strains caused by specific environmental conditions, such as avian flu viruses. The ubiquitous nature of many biological agents favours humanexposure through different routes, including food and water.

Though largely under control thanks to sophisticated policies adopted in the EU, food and drinking water safety issues are still responsible for a significant number of deaths. In humans, the severity of the associated health effects ranges from mild and temporary symptoms, as for most food-borne intoxications and infections, to chronic diseases caused by chemical contaminants such as chlorinated dioxins, acrylamide, perfluorinated chemicals and aflatoxins. To maintain the high levels of food safety achieved in the EU, It is necessary to keep high levels of attention, without overlooking the possible presence in food, besides contaminants, of naturally occurring toxic substances. Regarding drinking water, several areas in Member States are known to contain relatively high levels of arsenic, a known carcinogen; furthermore, salt contents in drinking water is too high in several states of Central EU. Overall, about 10% EU citizens are served with water not complying with the regulations in force. Moreover, drinking water quality is not adequately controlled in rural areas not connected to municipal delivery systems. Water availability is usually satisfactory, although a considerable proportion of the EU population lives in areas consuming more than 20% of their natural water resources. Also highlighted is that exposure to a number of non-food consumer products can result in significant health effects, especially allergic reactions, while the assessment of the health effects resulting from multiple exposures (either to the same substance through different exposure routes or to different substances) remains a complex task.

The health impact of the living environment can be [exacerbated by low quality housing. For example, dampness and moulds, major causes of respiratory infections and allergies in children and other susceptible persons, are present in an average of 16% houses, with wide variations among EU Member States. Crowded households are another issue in the EU, estimated to affect from less than 10% to more than 25% of the national population. This burden is carried mostly by large families and poor households, and generally speaking is not evident from national averages, which vary between 2 and 3 residents per household. The problems associated with the home setting, can also be present in the school setting, which, besides home, is the most important indoor living environment for children and adolescents. Ad hoc studies have shown that a decrease of the room temperature from 25 to 20°C was associated with a higher speed in carrying out some school tests by children aged 10-12 and that performance improved with increased ventilation. Data available on the health impact of urban, industrial and rural settlements indicates that residents in rural areas are more prone to accidents and to reduced access to health services. On the other hand urban and industrial settings are often characterized by non-adequate waste disposal, limited availability of public gathering places and green areas for social and recreational activities and by more aggressive social relationships. Only half of the European cities taking part in the Urban Audit had green spaces within a 15-min walking distance. Public transportation can have a very important health impact in some urban settings, in connection especially with noise and air pollution.

Although having an occupation is in itself an important health promoting factor, work activities and the working environment also have an important impact on health. In the EU, 165000 deaths each year are related to work, of which 160000 are due to occupational diseases and the remaining part is due to accidents. The incidence rate of occupational diseases (only a limited number of many pathologies related to work are currently recognized as occupational diseases) in male workers is 80 per 100000, twice that the rate in female workers. The 5 most common occupational diseases are hand or wrist tenosynovitis, noise-induced hearing loss, lateral epicondylitis, contact dermatitis and carpal tunnel syndrome. The incidence of non fatal occupational diseases is much higher in the mining industry (more than 1800 per 100000). Construction and manufacturing sectors also have incidence rates in excess of twice the average rate for all sectors (app. 60 per 100,000).

Social factors are also another group of human health determinants. It is well known that in all EU Member States, premature mortality and morbidity rates are higher among people with lower education level, occupational class or income. These health inequalities are observed in all the life stages and for both sexes, but being generally less dramatic in women than in men. Health inequalities are not confined to the poorest members of the society, but there is a gradient of mortality and morbidity across the entire society. Social networks, i.e. the social connections both at work and in private life, can have an important influence on mental health status.

The individual health status is related, with different strengths of association, to the past and current experience of specific threats (exogenous agents, factors or stressors of different nature), but is also influenced by factors such as genetic constitution, age, nutrition, lifestyle and socio-economic factors such as poverty and education. An up-to-date understanding of the actions of all these factors and of their interactions is critical for the definition and development of effective preventative health policies.

The development, improvement and implementation of health policies is for the Member States, in coordination among themselves and with the European Union as appropriate. This Report provides a detailed description of the current Community policies in different sectors with some reference to national policies. To this aim, each chapter dealing with a specific disease or health determinant includes a section on the current control tools and policies. The examination of this vast collection of information allows the identification of the sectors where policies are well developed, and those where there is still room for further development. Existing policies show both fragmentation and overlap. To improve this situation, it would be necessary, both at national and Community level to develop a shared strategic framework to tackle all health determinants, including the socio-economic ones, and their interactions. Public health should be considered a major part of social policy. One of the major tasks is the promotion of social conditions which ensure good health for the whole population; within this aim, special actions are necessary for the most vulnerable population groups. Since many different sectors of society have implications and bearings on public health, it is important to establish goals which can be regarded as guiding principles for the work already undertaken in a number of sectors. Taking into account that specific health determinants are responsible for a number of health consequences, the health goals should not be based on diseases or health problems only, but, preferably, on the most relevant determinants and interactions. The key points of the way forward have been identified and described as follows: setting priorities in public health; scientific research and innovation; and civil society involvement and mobilization.