International Health Regulations - WHCA



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Children’s Environmental Health:

Monitoring European Ministerial Commitments

Vienna

12-13 June 2007

Meeting Report

Background

The World Health Editors Network (WHEN), with WHCA () and WHO Regional Office for Europe (Euro.who.int), held a journalist briefing meeting on Children’s Environmental Health: Monitoring European Ministerial Commitments in Vienna on 12-13 June 2007.

The meeting preceded a WHO Regional Ministerial gathering—the Intergovernmental Mid-term Review (euro.who.int/imr)—at which the 53 countries in the WHO European Region reported on their progress in developing children’s environment and health action plans (CEHAPEs) and implementing actions addressing commitments made in Budapest in June 2004[1] related to preventing injuries, promoting physical activity, and ensuring safe water, clean air and chemical-free environments for “The Future of Europe’s Children”.

Journalists and editors who attended received an early and exclusive look at new country and regional data on children’s environmental burden of diseases, the latest findings on climate change, planned road and chemical safety campaigns and new monitoring tools. WHO officials, Governmental and NGO experts and advocates gave short briefings and answered questions.

The meeting was held (and this report is written) under Chatham House rules.[2]

Topic Summaries (see agenda attached at Annex 1)

1.0 Country data on environmental impacts on health

Nearly 5,000 deaths a day in Europe related to environmental causes are preventable. This is the conclusion of a World Health Organization (WHO) report released on 13 June 2007 showing the environmental burden of disease in the 53 countries of the WHO European region (who.int/quantifying_ehimpacts/countryprofiles/en). WHO claims that well-tested environmental health interventions could help reduce this number of deaths, saving up to 1.8 million lives per year.

The main causes of these deaths are air pollution, water-borne illnesses, accidents and injuries and chemical-related problems. These environmental problems lead to diseases such as asthma and respiratory infections, diarrhoea, vector-borne diseases, cancers, neuro-developmental disorders, cardiovascular diseases, and other injuries.

The report ranks countries by the size and proportion of death and disease due to environmental factors. Northern and Western European countries are at the top of the table, with the lowest risk. The countries of highest risk are Ukraine, Belarus, Kyrgyzstan, Tajikistan, Turkmenistan, Kazakhstan and, bottom of the table, Russian Federation. WHO reports that in Russia, the number of deaths due to environmental factors per year is 493,116 (see table 1).

Participants commended WHO representatives for publishing a league table. Such independent credible league tables are very valuable for public health advocates, particularly in countries with a free media and opposition parties, as the comparison can stimulate useful open discussions on corrective actions. Past publications of WHO league tables (e.g. World Health Report 2000) met with strong reactions from Member States who were not ranked high and consequently WHO have tended since that time to group countries in reports. Participants felt that “grouped data” does not clearly identify which countries are doing well and which are doing poorly and as such does not provide advocates with such a strong evidence base upon which to push for change.

Table 1: Preventable environmental impact on mortality and morbidity in countries of the WHO European Region (Excerpt from WHO, Country profiles of the environmental burden of disease, 2007)

|Subregion |Country |DALYs due to |% DALYs (burden of disease) due to|Estimated deaths due to |

| | |environmental |environmental factors |environmental factors |

| | |factors/1000 capita | | |

|  |  |  |Total   1,761,935 |

|EurA |Iceland |13.7 |14% |317 |

|EurA |Israel |14.1 |13% |5,594 |

|EurA |Switzerland |14.6 |13% |9,543 |

|EurA |Sweden |15.1 |14% |14,468 |

|EurA |Monaco |15.5 |14% |42 |

|EurA |Malta |15.6 |14% |490 |

|EurA |Netherlands |15.8 |14% |21,830 |

|EurA |Italy |16.0 |14% |90,809 |

|EurA |Norway |16.1 |14% |7,502 |

|EurA |San Marino |16.3 |15% |44 |

|EurA |Austria |16.3 |14% |11,424 |

|EurA |Germany |17.1 |14% |132,169 |

|EurA |France |17.2 |14% |80,107 |

|EurA |Spain |17.3 |14% |58,495 |

|EurA |Cyprus |17.5 |13% |1,363 |

|EurA |Andorra |17.6 |14% |91 |

|EurA |Ireland |17.8 |14% |5,286 |

|EurA |Luxembourg |18.0 |15% |574 |

|EurA |United Kingdom |18.1 |14% |101,335 |

|EurA |Belgium |18.7 |14% |17,032 |

|EurA |Denmark |19.1 |14% |9,235 |

|EurA |Finland |19.1 |15% |8,167 |

|EurA |Portugal |19.7 |14% |15,445 |

|EurA |Slovenia |19.8 |14% |2,926 |

|EurA |Greece |20.0 |16% |19,966 |

|EurA |Czech Republic |21.4 |15% |17,606 |

|EurA |Croatia |23.0 |14% |8,374 |

|EurB |TFYR of Macedonia |23.7 |15% |3,137 |

|EurB |Slovakia |25.1 |16% |9,315 |

|EurB |Poland |25.2 |17% |66,113 |

|EurB |Bosnia-Herzegovina |25.6 |16% |6,172 |

|EurB |Armenia |26.3 |16% |4,712 |

|EurB |Serbia-Montenegro |26.8 |15% |21,023 |

|EurB |Georgia |27.1 |16% |10,874 |

|EurC |Hungary |28.0 |16% |21,740 |

|EurB |Bulgaria |28.6 |16% |18,469 |

|EurB |Albania |29.9 |19% |4,425 |

|EurB |Uzbekistan |30.1 |18% |33,479 |

|EurB |Turkey |30.4 |19% |86,712 |

|EurB |Romania |30.8 |17% |46,928 |

|EurC |Lithuania |33.7 |19% |8,332 |

|EurC |Republic of Moldova |34.5 |17% |8,952 |

|EurB |Azerbaijan |35.7 |19% |12,927 |

|EurC |Latvia |38.3 |18% |6,492 |

|EurC |Estonia |38.7 |20% |3,732 |

|EurC |Ukraine |43.2 |19% |155,230 |

|EurC |Belarus |43.4 |20% |29,712 |

|EurB |Kyrgyzstan |46.2 |21% |9,706 |

|EurB |Tajikistan |47.5 |21% |12,021 |

|EurB |Turkmenistan |48.5 |22% |9,108 |

|EurC |Kazakhstan |49.3 |20% |39,274 |

|EurC |Russian Federation |53.7 |20% |493,116 |

Estimates based on 2002 data

2.0 Environment and health reporting in CEE

The message from journalists was that the countries in Eastern Europe with the highest environmentally attributable disease burden are countries where public awareness and political commitment are low. Journalists can help stimulate action by raising awareness of the issues, tracking progress on “promises” and investigating causes of inaction.

Being an environmental journalist in the CEE region can be difficult and dangerous. Environmental journalists, it was reported, are too often undermined and threatened by political and economic interests. They can be criticized for both being too green or not green enough. These journalists are often marginalized and environment correspondent jobs given to inexperienced journalists.

Addressing these difficulties, it was noted, requires some courage and persistence. Assistance by international agencies such as WHO can help. On a general level, there is a need to acknowledge the difficulties and champion the critical need for reliable public health environment reporting. On a practical level, there is a need for better training and capacity building, greater access to reliable sources, and trans-boundary and regional networking. It was also noted that press officers of agencies should understand the reality of the working conditions, and give good stories that are easy to follow and do not contain lots of jargon and abbreviations.

Journalists also expressed concern about a number of WHO publications and fact sheets that are only available in English. While not a problem for bilingual journalists, they believe policy makers and the general public are less likely to take notice when these important materials are not in their first language.

3.0 Injuries[3]

Key Message - “ Injuries are no accidents”

Over 2,000 people die from injuries in the European Region of WHO each day. For each fatality, 60,000 other people are hospitalized and 600,000 require Outpatient Emergency treatment. Evidence collected across the Region and beyond indicates that relatively simple and effective policy interventions can drastically reduce the human, financial and societal costs associated with injuries. If all countries in the European Region performed as well as the best, two out of three injuries would be prevented.

3.1 It’s Time to Stop Blaming the Victim

Action to prevent injuries requires a paradigm shift away from abrogating responsibility solely to individuals and instead promoting safety through organized efforts of society to provide safer physical and social environments. Safety can only be assured if governments, both national and local, and society as a whole take action.

|High-level political commitment can result in quick and visible gains |

|An example of where strong political leadership led to improved safety on the roads is from France. In view of the fact that road traffic|

|accidents were the leading cause of death in young people, President Chirac made road safety a national priority in his Bastille Day |

|speech in July 2002. This led to the formation of an inter-ministerial committee and the formulation of a National Plan of Action. The |

|plan of action provided the necessary mandates empowering the various agencies to take action at both a national and local level. This |

|has led to a 34% reduction in road traffic injury deaths over a two-year period (2002-4). This was through the implementation of |

|preventive measures such as speed control, traffic calming, seat belt use and control of drink driving. The health sector played an |

|important contributory role. |

3.2 Save Lives— Reduce Suffering

There is potential to save about 500,000 lives (68%) from injuries in the Region if all countries had the same death rate as the lowest in the Region. For children, this amounts to 75% of childhood injury deaths, or about 15,000 deaths.

Nowhere else in the world is the difference between poor and wealthier countries in terms of injury mortality as high as in the European Region. Changes in the physical, political, social and cultural environments in the East of the Region have led to large increases in the occurrence and mortality from unintentional injuries and violence. These are amongst the highest in the world. In contrast, some countries in Western Europe are the safest in the world in terms of injuries and violence. Furthermore, Europe’s population is undergoing a demographic transition with an aging population in most countries and a falling birth rate. Certain groups are more vulnerable to injuries, including children, older people and those who are poorer.

The contrasting situation between different parts of the Region and within countries presents both threats and opportunities. The threat is that the high death rates from injury will continue or worsen. The opportunity is that the situation can be improved by using the experience from countries with a good safety record. This has involved giving greater visibility to injuries and recognising their preventability, by listening to demands from civil society and by organised efforts of society to develop and implement effective preventive strategies. Creating and developing safer environments requires a multi-sectoral approach that puts safety first in health and social policies.

3.3 Reduce Costs—Free up the Health Workforce

Injuries are an important cause of health service expenditure, and make demands on already overstretched health service resources. Although health care costs for injuries are not widely available for the Region, estimates have been made for this report. The figures are staggering. For example, in 1999 hospital admissions alone for injuries arising in the home and from leisure activities cost about €10 billion for the 15 countries of the European Union before May 2004, or about 5.2% of the total Inpatient expenditure.[4] For the Region, the annual health care cost of treating patients who subsequently die is estimated at about €1-6 billion[5] and that of non-fatal injuries ranges from €80-290 billion.[6] Clearly, the benefits of using effective strategies of prevention would far outweigh the huge costs borne principally by the health sector, and society at large.

The economic costs of unintentional injuries and violence are vast and have only begun to be mapped out. Studies suggest that in the Region, 1-3% of country Gross Domestic Product (GDP) is lost in one year due to road traffic injuries alone.[7] The estimated economic costs of motor vehicle accidents are in the order of €180 billion in the 15 countries of the European Union before May 2004[8] (about 2% of GDP).[9] The majority of these costs are related to the injury, in which loss of productivity predominates. When it comes to violence, data for the Region are scarce. In England and Wales, a study estimated that total costs of €34 billion were attributed to violent crime—including homicide, wounding, and sexual assault. This tally includes both direct costs such as police, judicial system and health service costs, and indirect costs including lost productivity and physical and emotional costs.[10] Despite these startling figures, economic valuations underestimate the real cost paid by society, as they do not capture the suffering caused to families and social support networks of victims, as well as to communities, work places and school classes.

Some of the effective interventions to save lives and mitigate the effects of injuries are value for money, as shown in the table below.

|Value for money of selected injury prevention interventions |

|1 € spent on smoke alarms |Saves €69 |

|1 € spent on child safety seats |Saves €32 |

|1 € spent on bicycle helmets |Saves €29 |

|1 € spent on road safety improvements |Saves €3 |

|1 € spent on prevention counselling by paediatricians |Saves €10 |

|1 € spent on poison control services |Saves €7 |

|1 € spent on universal licensing of handguns |Saves €79 |

|1 € spent on home visitation and parent education against child abuse |Saves €19 |

Adapted from WHO 2005, Injuries and Violence in Europe, p10

3.4 Buck the Trends

Recent trends show that for the Commonwealth of Independent States (CIS)[11] injury mortality trends are getting worse, but are getting better in the European Union (EU).[12] Figure 1 shows trends since 1980 for standardised mortality rates from injuries for the European Region, for the EU and the CIS. These show that when the whole of the European Region and the CIS are considered, there have been two upward trends, one which peaked in 1994 followed by a fall, and then a second which has been climbing since 1999.

The upward trends in some of these countries in transition have been studied. They are thought to be due to factors such as increases in road traffic, worsening inequalities in wealth, higher unemployment, decreases in social capital, liberalisation and the increased availability of alcohol, and poor regulatory and enforcement mechanisms.

Figure 1: Trends in standardised mortality rates for all injuries in the European Region from 1980-2003 (Source: HFA-MDB)

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Source: WHO 2005, Injuries and Violence in Europe, p6

There are large inequalities in the Region, with rates being highest in the east and south of the Region. Child mortality rates in the WHO Region follow the same pattern as the rates for overall deaths to environmental causes—lower in Nordic, West, and South European countries, higher in the Baltic and CIS region. Sweden has the lowest rate of child mortality—3.6 per 100,000. If this level was reflected across the WHO Region, then over 15,000 lives (75%) could be saved.

Using data from 2002, the Russian Federation has the highest standardised mortality rate from injuries (229.1 per 100,000 population) whereas the United Kingdom has the lowest (27.3 per 100,000 population). This means that the risk of someone dying from injuries in the Russian Federation is over eight times higher than that in the United Kingdom. The average for the CIS countries taken as a whole was almost four times higher than that of the EU.

|Key facts on inequalities and social determinants |

|There are inequalities in the Region, with some of the highest rates of injury deaths in the world in the CIS and some of the lowest rates |

|in western Europe. |

|Poorer people are more likely to die from injury than the more wealthy. |

|This is an important area of social justice. |

|Injuries and violence are a cause of premature death in people living in relative poverty. |

|Social exclusion, the loss of social support networks and changes in social capital have been witnessed in many countries of the CIS and |

|Eastern Europe which have undergone transition. |

|(adapted from Sethi, et al 2005) |

For more information see euro.who.int/violenceinjury.

4.0 Climate Change[13]

Key message – Climate change effects are visible now and action should be immediate for both mitigation and adaptation

4.1 Definitions[14]

Climate change refers to a statistically significant variation in either the mean state of the climate or in its variability which persists for extended periods (typically decades or longer). The Earth’s climate system has demonstrably changed on both global and regional scales since the pre-industrial era, with some of these changes attributable to human activities. Human activities have increased the atmospheric concentrations of greenhouse gases and aerosols since the pre-industrial era. The atmospheric concentrations of key anthropogenic greenhouse gases (i.e. carbon dioxide (CO2), methane (CH4), nitrous oxide (N2O), and tropospheric ozone (O3)) reached their highest recorded levels in the 1990s, primarily due to the combustion of fossil fuels, agriculture, and land-use changes. An increasing body of observations gives a collective picture of a warming world and other changes in the climate system.

|Mitigation refers to actions that limit the amount and rate of climate change (the “exposure”) by constraining the emissions of greenhouse |

|gases or enhancing their sinks. |

| |

|Adaptation, in contrast, refers to any actions that are undertaken to avoid, prepare for or respond to the detrimental impacts of observed or |

|anticipated climate change. Mitigation and adaptation vary significantly in their scope, type of actions, characteristic spatiotemporal |

|scales, and principal actors. Mitigation is the only strategy that can reduce impacts of climate change on all systems and on a global scale |

|but it requires international cooperation and takes a long time to become fully effective because of the inherent inertia of the climate |

|system. Adaptation can address climate-related risks in human-managed systems on a local or regional scale and on a shorter time scale but its|

|scope is generally limited to specific systems and risk types. |

| |

|Planned adaptation to the health impacts of climate change comprises a wide range of preventive public health measures. Eventually, |

|behavioural changes, medical interventions, or the use of technologies will be required to reduce climate-related health effects. The public |

|health sector and other relevant sectors may facilitate these actions by appropriate educational, institutional, legal and financial measures,|

|and other policy changes. Because the measures considered in adapting to future climate change are, in general, not new, most of them also |

|reduce the vulnerability to current climate variability. However, adaptation to climate change may require action by people who have not |

|considered climate an important factor for their decisions in the past. |

|Adaptation also refers to the process by which adaptive measures are implemented: it can be immediate and intuitive (eg buying a fan to cope |

|with the heat), but it can also involve a long process of information collection, planning, implementation and monitoring (eg setting up an |

|early-warning system for heat stress). The terms “autonomous adaptation” and “planned adaptation” are generally used to distinguish between |

|these two types of adaptations, even though the distinction is not always sharp. Planned adaptation may be a response either to perceived |

|changes in climate and associated health risks (“reactive adaptation”) or to anticipated risk changes in the future (“proactive” or |

|“anticipatory adaptation”). |

4.2 What are the climatic risks Europe might be facing? (WHO, 2005)

In Europe, over the last 50 years there has been an increase in minimum and maximum temperatures, changes in precipitation characteristics and increases in the magnitude and frequency of extreme events such as high temperatures, heavy precipitation and persistent dryness.

Current trends point to a reduction in continental temperate climates: southern Europe is likely to become drier, while in northern Europe climate is likely to become milder and wetter. Episodes of heat waves, periods of prolonged dryness and drought, heavy precipitation, storminess, and storm surges are expected to increase.

In 2002 the WHO European Region was hit by a major flood and in 2003 by a severe heat wave. Experience seemed to confirm what models had predicted. Although one record heat wave and flood does not prove that Europe is getting hotter or the weather more extreme, the impacts of these events can be considered an early test of current coping strategies. Lessons learned point to the need for strengthening policies which will help societies better adapt to such extreme changes in Europe’s climate.

| |

|Box 1: Lessons from the 2003 heat event in France |

| |

|A severe heat event in August 2003 resulted in an estimated 14,800 excess deaths in France. Metéo France issued warnings to the media, but |

|these were not passed on because authorities did not understand the potential scale of the impact. Deaths were not detected in real time |

|because data from emergency and medical services and from death certificates were not used for health surveillance. An inquiry by the General |

|Directorate of Health (DGS) concluded that the 2003 heat event was unforeseen, was only detected belatedly and that it highlighted |

|deficiencies in the French public health system, including a limited number of experts; lack of preparation for a heat event, including |

|defining responsibilities across public organisations and developing effective mechanisms for information exchange; health authorities and |

|crematoria/cemeteries overwhelmed by the influx of patients and bodies; few nursing homes equipped with air-conditioning; and a large number |

|of elderly people living alone without a support system and without proper guidelines for appropriate responses to a heat event. These |

|conclusions indicated the need for strong international surveillance of emerging risks, for more research into the health consequences of heat|

|events, and for better coordination between the expert agencies and research bodies. |

| |

|One issue that arose was that the ministry with primary responsibility for managing a heat event varied by how heat events were classified. If|

|a heat event was classified as a natural catastrophe, then the ministry of the interior would have primary responsibility. But if a heat event|

|was classified as a health catastrophe, then the ministry of health would have primary responsibility. |

|Since 2003, the French government has formulated short- and medium-term actions to reduce future health impacts from heat events, including |

|sponsoring research on the risk factors associated with heat-event-related mortality, implementing a health and environmental surveillance |

|programme, and developing national and local action plans for heat events. If effective, these actions should reduce future vulnerability to |

|heat events. |

| |

|(adapted from WHO 2005, p11) |

4.3 What are the potential health impacts?

Every epidemiologist knows that climatic factors are important determinants of human health and well-being. Ambient temperatures outside the comfort range that a population is acclimatized to are associated with thermal stress; weather-related disasters, such as floods and storm surges, cause significant loss of life; and many infectious diseases are limited to certain climatic zones. Climate change can cause direct damage through exposure to hazardous meteorological conditions and indirect impacts such as vector-, rodent-, water-, and food-borne diseases and aeroallergens, through a mediation of climatic factors in a climate sensitive environmental system.

The history of human adaptation to climatic factors comprises great successes as well as disastrous failures. On the one hand, humans have successfully managed to live in nearly every climatic zone on Earth, from the Arctic ice to the hot deserts. On the other hand, the rise and fall of many great civilizations has been linked to regional climatic shifts, including the establishment of the first Chinese dynasty, the collapse of ancient civilizations in Egypt, the Indus Valley, and Mesopotamia, the discontinuity in ancient Greek civilization, and the decline of the Maya culture.

Current health impact evidence points to:

• increases in mortality and morbidity, principally in older age groups and the urban poor, from the increase in frequency or intensity of heat waves;

• the health effects of acute climate change and extremes (storms, floods, cyclones, etc.) related to physical damage, population displacement, and adverse effects on food production, freshwater availability and quality, and associated increases in the risk of infectious disease epidemics;

• ecosystem and other changes affecting some vector-borne infections and infecting population particularly at the margins of current distribution of diseases;

• rising pollen counts contributing to asthma; and

• air quality deteriorating in many large urban areas.

Actual health impact, in any given country, will depend on the extent to which health, or the natural or social systems on which health outcomes depend, are sensitive to the changes in weather or climate; the characteristics of the population; the exposure to the weather or climate-related hazards, and importantly the measures and actions in place to reduce disease outcomes.

Experts surveyed in the cCASHh study (euro.who.int/mediacentre/PR/2005/20051205_1) ranked income, equality, type of health care system, and quick access to information as most important factors enabling effective response to climate change. Countries in the WHO European Region vary tremendously in their capacity to respond.

Those with the highest adaptive capacities tend to have high incomes, universal health care coverage, and high access to information. Concerns were raised about a negative impact on “adaptability” in parts of Europe where inequalities are rising, investment reduction in prevention is noted, and populations are aging.

What action can be taken now?

The design and implementation of adaptation policies and measures primarily focuses on existing climate-related risks to human health because most of the health outcomes projected to increase with climate change are also current problems. Likely responses will range include:

• modification of existing prevention strategies, including the introduction of new measures or higher settings of existing measures;

• translation of policies and knowledge from other countries or regions to address changes in the geographic range of disease;

• reinstitution of effective surveillance, maintenance and prevention programmes that have been neglected or abandoned; and

• development of new policies to address new threats.

Approaches to be taken include adjusting existing programmes to take increasing weather variability and change into account; implementing effective disease-specific policies and measures employed in other countries and regions when a disease changes its geographic range; and developing new policies when new threats arise, e.g. heat wave national action plans. There is a need for implementation at pan-European, national, and local levels.

Characteristics of action

• Anticipatory—e.g. early warning systems;

• Active and vigilant—e.g. early disease detection;

• Incremental—e.g. disease monitoring and surveillance;

• Health benefits oriented in cross- and multi-sectoral measures—e.g. flood structural and non-structural measures;

• Open to knowledge and technology transfer from other sectors, countries and regions.

For more information see euro.who.int/InformationSources/Publications/Catalogue/20051206_1.

5.0 ENHIS

The European Environment and Health Information System (ENHIS) is designed to identify environmental health problems in Member States. It uses indicators to assess, monitor and communicate information on these problems, and a Health Impact Assessment to look at the impact of policies either implemented or planned.

Through ENHIS, the report Children’s Health & Environment in Europe: Baseline Assessment used 26 indicators based on the four RPGs to build an evaluation of the priority issues across the WHO European Region. Although comparing countries, it is not meant to be seen as criticism, more highlighting the problems in order to stimulate action. The first full assessment will be at the 2009 Ministerial Conference.

The collection of data will not add extra burdens to member countries, as it uses existing reporting systems agreed with countries, which promote monitoring.

Concerns were raised by journalists that some governments, particularly in eastern Europe and CIS, were not providing accurate and timely data. It was noted that much of the data in these countries originated from NGOs and government input was minimal.

Example of ENHIS data presentation

Key message: RTIs are the leading cause of death in children and young people in the Region and the rates are unacceptably high. An eightfold difference exists between the lowest and highest rates in the Region. Encouragingly, the comparatively low mortality rates achieved by some countries indicate that deaths from RTIs are preventable. This underscores the urgent need to implement safe transport policies and preventive strategies.

Figure 2: SMRs for RTIs in children and young people aged 0–24 years in the WHO European Region, as averages for 2002–2004 or the most recent three years

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Source: object_class/enhis_home_tab.html (accessed 17/08/07)

For more complete information see object_class/enhis_home_tab.html.

6.0 REACH

REACH is the Registration, Evaluation, Authorisation and Restriction of Chemicals, a European Law that came into force on 1 June 2007. REACH aims to improve the identification and classification of chemicals. The safety of 90% of the up to 100,000 chemicals on the market is unknown, and toxic chemicals have been linked to diabetes, thyroid diseases and cancers, among other health problems.

High-concern chemicals will be the first to be classified, but this process will not be finished until 2009. Labels for all products are possible by 2010. In the meantime, consumers can ask companies what chemicals of concern are in products and how they should be used and disposed of and must receive replies within 45 days. However, the legislation does not specify punitive punishments for failures to comply.

REACH is regarded as a significant step forward, but needs to be substantially strengthened. The Health and Environment Alliance (HEAL) launched its Chemical Health Monitor project at the meeting, a watchdog to ensure the proper implementation of REACH.

See IMG/pdf/REACH_EIF_Open_letter_version_FINAL.pdf. Also, see , an alliance of NGOs focused on chemicals. Here is a statement from them:

“After nearly nine years of debate, the European Parliament and the European governments finally gave their stamp of approval to the new EU chemicals law, REACH. Approved in December 2006, REACH will cover approximately 30,000 of the 100,000 chemicals currently available on the European market, taking a first, modest step towards a new and safer approach to chemicals regulation. Among its strongest points, REACH will require companies to provide safety data for large volume chemicals that they produce or import into the EU, and companies will have to substitute chemicals that persist in the environment or build up in our bodies with safer alternatives whenever they are available.

For the first time, with the new REACH regime, the public has the right to obtain information about the presence of some very hazardous chemicals in consumer products. Until now companies could use almost any chemical they liked to manufacture their products without providing health and safety information. As a result, hazardous chemicals were only restricted from the market on a case-by-case basis, mainly in response to health and environmental scandals.

While there remains much to strengthen in the new law, REACH sets us in the right direction with the framework to provide the public with information about the health and environmental effects of chemicals (many of which are present in consumer products of everyday use) and to phase out the most hazardous substances if safer alternatives are available (the Substitution Principle).

REACH will come into force in June 2007, but it will take a long time before citizens reap the benefits of this new legislation. The process of providing safety data (registration) for chemicals will only be completed in eleven years. Moreover, many important decisions have been postponed for future revisions of the law. For example, the EU will wait six years before it decides whether or not to require the substitution of powerful hormone mimicking chemicals with safer alternatives.

Unfortunately, the legislation contains major loopholes. Concessions granted to the big chemicals industry may allow companies which import and manufacture chemicals in volumes below 10 tonnes per year—60% of chemicals covered by REACH—from the requirement to provide any meaningful safety data.

Moreover, REACH will still allow many chemicals that can cause serious health problems, including cancer, birth defects and reproductive illnesses, to continue being used in manufacturing and consumer goods. Even if safer alternatives to those dangerous substances are available, many of these chemicals of very high concern will be allowed onto the market if producers claim that they can ‘adequately control’ them. The approach of adequate control—and safe thresholds—is flawed and premised on a risky gamble, given the unknown effects of chemicals in combination, on vulnerable hormone functions, and on the development of children from the earliest stages of life. Medical associations, consumer groups and innovative businesses across Europe had called for a legal requirement to substitute them with safer alternatives as the minimum necessary measure against hazardous chemicals.

The loopholes and provisions for self-regulation contained in the law leave REACH very vulnerable to further manipulation by the chemical industry. There remains plenty of room for the chemical industry to manoeuvre around the loopholes to keep hazardous substances on the market. The new EU Chemicals Agency in Helsinki will have to be closely monitored to ensure that REACH can deliver. Without the necessary support, hazardous chemicals will continue to contaminate wildlife, our homes and our bodies, and REACH will prove a failure.

This is why in the future we will need to keep careful watch over how the law is put into practice and to ensure that REACH delivers. You, as citizens and consumers, must make your voice heard and demand safe products and environment. Environmental and many other public interest organisations will continue to campaign for a toxic free future. Support an organisation in your country that works on chemicals …” (, accessed 17/08/07).

7.0 International Health Regulations

The first version of the International Health Regulations (IHR) was published by WHO in 1969 to monitor and control cholera, yellow fever, plague and smallpox (later excluded), for a harmonised way of dealing with diseases.

For the 21st century, in a new globalised world of international trading and travelling, with the rapid spread of diseases such as Avian Flu’ and SARS, an updated version was clearly required. The new IHR were adopted unanimously on 23 May 2005 and came into force on 15 June 2007.

They require countries to report all public health threats of international concern and to establish a national IHR Focal Point (NFP) to provide information to, and receive information from, WHO any time. In a 24/7 news media world, it is harder for authorities to cover up an outbreak. Over 50% of information sources on outbreaks are non-official (and 50% of outbreaks identified through media reports), so the revised IHR are designed to improve both the reporting mechanism of and the response to public health risks of international importance.

Although legally binding, there are no ‘punishments’ as such, although failure to comply would lead to a tarnished international image, disruption, travel and trade restrictions, public outrage and increased deaths.

WHO has published extensive information on the new International Health Regulations. See Frequently asked questions at who.int/csr/ihr/howtheywork/faq/en/print.html.

| |

|Box 2 : Frequently asked questions about the International Health Regulations (2005) |

| |

|General |

|1. What are the International Health Regulations (2005) and why does the world community need them to enhance international public health |

|security? |

|2. What is the history of the IHR? |

|3. Why were the IHR revised? |

|4. What are the major changes in the IHR (2005)? |

|5. What is meant by a 'public health emergency of international concern' in the IHR (2005)? |

| |

|The legal framework established by the IHR (2005) |

|6. What is the legal status of the IHR (2005) and how do they enter into force for States? |

|7. How will compliance with the IHR (2005) be achieved? |

|8. How will questions or disputes on the interpretation or application of the IHR (2005) be resolved? |

| |

|The roles, responsibilities and obligations of States Parties and WHO under the IHR (2005) |

|9. Who will be responsible for implementing the IHR (2005)? |

|10. How will States benefit from the IHR (2005)? |

|11. According to the IHR (2005), what are the key obligations for States? |

|12. According to the IHR (2005), what are the key obligations for WHO? |

|13. How will WHO gather public health information and obtain verification thereof? |

|14. When and how will WHO issue recommendations concerning public health emergencies of international concern? |

| |

|Travel and trade under the IHR (2005) |

|15. How will the IHR (2005) affect international travel and trade and individual travellers? |

|16. How and why States Parties are required to designate international airports and ports and may designate certain ground crossings for |

|capacity strengthening purposes under the IHR (2005)? |

| |

|Collaboration under the IHR (2005) |

|17. How do the IHR (2005) interact with other international agreements and bodies? |

|18. How will the IHR (2005) affect the Model Deratting and Deratting Exemption certificates, Maritime Declaration of Health, International |

|Certificate of Vaccination or Revaccination against Yellow Fever and the Health Part of the Aircraft General Declaration? |

| |

|Specific diseases under the IHR (2005) |

|19. How do the IHR (2005) help to address the risk of an influenza pandemic in humans? |

|20. What kind of yellow fever vaccines are valid under the IHR (2005) and must they be administered at a vaccination centre designated by the |

|State or at a listed WHO-approved vaccination centre? |

| |

|who.int/csr/ihr/howtheywork/faq/en/print.html (accessed 17/08/07) |

8.0 Conclusion

Following the briefing, journalists attended the opening and plenary sessions of the IMR and had opportunities to interview key presenters and national representatives. Based on these briefings and conference sessions, participants produced a variety of articles published in national newspapers, web pages and television outlets. Examples of these articles are included in Annex 2.

ANNEX 1 – AGENDA

|Tuesday 12 June : LEBENMINISTERIUM, ZIMMER 36/1.STOCK (ROOM NR. 36/1ST FLOOR) STUBENRING 1, 1010 VIENNA |

| | | |

|13.30 |Registration | |

|14.00 |Welcome and overview |Franklin Apfel |

| | |Cristiana Salvi, WHO |

|14.15 |Children’s Environment and Health: Spotlight on Ministerial |Roberto Bertollini, WHO |

| |Meeting, 13-15 June — how well are countries doing? | |

| |News — New European Country Burden of Disease Data | |

|15.00 |Eastern European Perspectives |Eva Csobod, Regional Environment Centre |

| |News — Ministerial “Report Card” from Independent Review |Pavel Antonov, Regional Environment Centre |

| |Panel | |

|15.30 |Coffee | |

|15.45 |Accidents and injuries — How well is Europe doing? |Francesca Racioppi, WHO |

| |News — New Comparative data on country interventions | |

|16.15 |Children's environment and health action plans for Europe |Michal Krzyzanowski, WHO |

| |(CEHAPE) indicator-based report: first assessment | |

| | | |

| |News — Launch of the web-based environmental health | |

| |information service enabling access to children's EH | |

| |indicators | |

|16.45 |Chemical safety — REACH |Lisette Van Vliet, HEAL |

| |News — New European Chemical Safety Campaign | |

|17.15 |The New International Health Regulations |Cristiana Salvi, WHO |

| | | |

| |News — IHR(2005) come into force June 2007 | |

|17. 45 |Climate Change and Health |Bettina Menne, WHO |

| |News — New Heat Wave Preparedness Guidelines |Lilian Corra, IDFE |

| |New EU survey on Climate Change and Infectious Diseases | |

|18.30 |Wrap-up | |

|19.30 |Reception |WHCA |

Wednesday 13 June

Join the Ministerial meeting at the Hofburg Center : Hofburg — Redoutensäle, Entrance: Josefsplatz 1, 1010 Vienna ()

|08.00 |Registration | |

|09.00 |Opening session addresses |Mr Josef Pröll, Federal Minister of Agriculture, Forestry, |

| | |Environment & Water Management, Austria |

| | |Dr Andrea Kdolsky, Federal Minister for Health, Family and Youth, |

| | |Austria |

| | |Dr Susanne Weber-Mosdorf, Assistant Director General, WHO |

| | | |

| | | |

|10.15 |Keynote Address |Dr Andrzej Ryś, |

| | |Director, Public Health and Risk Assessment Directorate; |

| | |DG Health and Consumer Protection, European Commission |

|10.30 |NGO Best Practice Award |An award presented to the 15 most sharing inspiring, innovative |

| | |and concrete activities that made a difference in improving |

| | |children’s environmental health across the 53 countries of the WHO|

| | |European Region at the IMR. |

|11.00 |Press Conference |Mr Josef Pröll, Federal Minister of Agriculture, Forestry, |

| | |Environment & Water Management, Austria |

| | |Dr Andrea Kdolsky, Federal Minister for Health, Family and Youth, |

| | |Austria |

| | |Dr Susan Weber, Assistant Director General Sustainable |

| | |Development, WHO |

| | |Dr Nata Menabe, Deputy Regional Director, WHO Regional Office for |

| | |Europe |

| | |Genon Jensen, Director, Health AND Environment Alliance (HEAL) |

| | |A youth representative |

|13.30 |Lunch | |

For full details of the IMR conference, go to : euro.who.int/eehc/conferences/20070327_2

ANNEX 2 - PARTICIPANT ARTICLES

Article by Xhemal Mato : Ekolevizja

[pic]

Article by Yuri Eldyshev : Ecology & Life magazine

[pic]

Article by Hanna Hopko : Day newspaper (day.kiev.ua), 5 June 2007, №.107

WHO: “Healthy” environment can save 13 million lives a year worldwide

Why Ministers from 53 countries gathered together

Ukraine occupies 47th place in mortality caused by polluted environment among 53 European countries, Byelorussia and Russia that takes the last place were left behind. And it is 155 thousand deaths a year. The first place was taken by Iceland that has 317 deaths (or 13% of total) caused by polluted environment. The experts from World Health Organization declared this data during the Ministerial meeting “The Future for our children” that was held in Vienna. It’s the first WHO’s report made by analyzing the influence of ecological factors on people’s health in every country. The new data also testify that for example only in Europe 1.8 million deaths could have been prevented by improving the state of environment. Worldwide “healthy” environment could saved 13 million lives.

An increasing number of morbidity and mortality among children that is connected with the polluted environment and global warming became a subject of discussions of about 400 participants. The WHO experts and other international organizations, the representatives of Ministries of Health and Environment from 53 European countries-members of WHO, public organizations and journalists gathered in the capital of Austria to listen to an interim Minister report on the threshold of the Major Minister Conference in Italy in 2009. Our correspondent Hanna Hopko discovered what Minister are doing to guarantee European children healthy environment.

IN VIENNA IN THE HEAT WEATHER... IT STILL EASY TO BREATH

In Vienna where the participants of Intergovernmental mid-term review ministerial conference “The Future for our children” gathered one can easily breathe in the heat. The reason isn’t only the parks that occupy 50% of the city. The clear air is one of the priorities of ecological policy of Austria for more than 10 years. In 1985 the limitation on utilization of lead in the fuel was instituted and in 1993 this harmful substance was totally prohibited. Austrian petrol became “sulphur-free” in 2004.

“We managed to reduce air emissions by implementing the benefits on diesel fuel and now we are seeking to use biofuel instead and to introduce the reduction of heavy gases from wagons and other commerce trucks”, - said Josef Prol, the Federal Minister of agriculture, forestry, environment and water management of Austria. By the way, the Austrians respect Prol for the reforms and achievements. He takes up this position for more than 5 years unlike in Ukraine, where practically each year change Ministers both of Health and Environment.

Thus not only refined fuel and new cars equipped with filters make the air safe. Here the cyclists have the separate roads and the bikes are not ashamed of: some of the rapporteurs in the lounge suits drove to the Conference on the two-wheeled cars with pedals.

In the ancient centre of the city around Hofburg – former imperial residence that used to be the centre of the Habsburg Empire up to 1918 and now became the meeting point for the Ministers – smells of horse dung. Dozens of luxurious carriages serve the tourists that are eager to see the historic part of the city through the windows of the carriage.

The Minister meeting in Vienna isn’t just a current opportunity for ministers and experts to talk and to exchange the experience. Austrian Government and the Regional WHO office in Europe, the organizers of the event, gathered the honorable participants for an interim report – an estimation of the results since 2004.

3 years ago in Budapest on the Fourth Minister conference “The European plan of actions for the environment and children’s health” was adopted. The document defined four regional priorities for 53 European countries: providing safe water and appropriate sanitary conditions in schools and other institutions; prevention of road traumas and provision of physical activity; provision of clear air both in the streets and apartments; trying to make environment chemicals-free. Every minister including ours promised to work out a regional plan in order to improve the situation in these four aspects.

According to WHO’s data the influence of environmental degeneration on people’s health remains the main cause of mortality and suffering around Europe, especially it influences children. As the most vulnerable part of society the children are extremely sensitive to ecological threats. Polluted environment causes third part of children deaths in Europe. Mortality caused with ecological factors increases on 34% among children and teenagers under 19. That’s why children and their future is the reason for actions of Ministers of both responsible Ministries in Europe since 1989 when the first conference in Frankfurt was held in order to improve environment and health. This meeting of Ministers of environment and health started the sequence of conferences that are held once in five years. The further conferences were in Helsinki (1994), London (1999) and Budapest (2004). The conference of 2009 will be held in Italy.

WEALTHY PEOPLE HAVE THEIR OWN “ECOLOGICAL” CAUSES OF MORTALITY.

After the new data from the last report of WHO were promulgated the conclusion was obvious, as the countries from the Western Europe took first places with the lowest rates of mortality caused by environment. “The meeting in Vienna helped us to realize that there’re huge differences in diseases and problems between the countries of Western and Eastern Europe for the inhabitants from the Eastern European region are more vulnerable. That’s why it’s important to create a bridge between us in order to destroy the gap”, - said Roberto Bertollini, the head of “Environment and health” WHO program.

Low-income countries suffer from ecological factors loosing in 20 times more healthy years of life on a person a year, than wealthy countries do. Even in the country with safe ecological conditions one sixth part of all diseases could be prevented. The effective interference in order to improve the environment may reduce the number of cardiovascular diseases and road traumas.

There’s also a divergence in perception of problems. For example, the Austrians cannot imagine a wrecked warehouse with improper pesticides in the midst of Alps or the absence of sinks in the toilets of rural schools. The sore subject for Austria is the road traumas problem. Among 170000 traffic accidents in 21% suffer children. The issue for the Austrians is how to reduce the distance between schools and houses to lower the possibility of injury.

FROM THE ACCESS TO DRINKING WATER TO SAFETY ON THE ROADS.

For the first time the representatives of European countries told about the learnt lessons and the experience in improving the environment for children. In Budapest already the Ministers of 53 European countries received a home task: each of them had to send a report about the activity and projects that are being run in order to improve children’s lives. It includes the legislation, propaganda of healthy way of living, increase the level of knowledge, perfection of services, monitoring the risks, caused by the environmental factors.

“Ukraine takes part in the process, though as Bertollini noted, not as effective as it would be desired. It’s a large state. We’re not very happy of few actions carried out and we’d like to see more engagement into the process. We’re glad to support you as far as we can. We know that the problems of the quality of water, air pollution and the mass character of the traffic accidents are on the high level. Furthermore the problems of tuberculosis and AIDS also exist.

Ukraine was represented by the first vice-Minister Sergiy Berezhnov and Oleg Kruzhnuy, the advisor to the Minister. There was not any representative from the Minister of environmental protection. Probably there was nothing to report about. (Though in Kiev vice-Minister of ecology on the question why there were no representatives besides the Ministry of health answered: “But we were present at the conference on the same subject in Austria in 2004 and then there was nobody from the Ministry of health”).

On the WHO’s site we’ve found a short report of our Ministry of health, in which the specialists mentioned as a separate problem the improvement of the air quality in Internet cafes. The teens and youth spend from 3 to 9 hours a day in these institutions especially at nights, when the services are cheaper. There are 3800 twenty-four-hour cafes in Ukraine. Usually the level of formaldehyde in the air exceeds the standards in 20 times; also children suffer from heavy metals. An additional anxiety also causes the mental retardation.

“A great attention is paid to the creation of the elementary sanitary conditions in the places where children stay, and it’s first of all schools, lyceums, for example, the banality of the school toilets. This question became mature so why not discuss it and accept the program “The school toilets”. In the cities this question is solved, though in the rural regions it’s a burning question: the significant part of these toilets is outside and not well-equipped. In summer there’s no water and the toilets aren’t connected to the sewerage system. And merely aesthetic school conditions aren’t very pleasant. Such objects may become a mechanism of the appearance and spreading of the infections, because in schools there’re no elementary conditions for washing hands”, - said vice-Minister of health Sergiy Berezhnov about the situation in Ukraine.

€1000 “PREMIUM” FOR THE IMPROVEMENT OF THE ENVIRONMENT FOR CHILDREN

Solving the problem of the environmental improvement for the children’s health is the field for thousands of research and scientific institutes, public organizations. During the Minister meeting the rewarding of the finalists of the contest “Ecological measures to save children’s lives”, announced in March 2007, was held. Five winners received diplomas and €1000 that were donated by the Ministry of Austria. All in all more than 100 projects from 31 countries were received. The criterions that were estimated: connection of health with environment; facility in fulfillment; low expenses and effectiveness; possibility to use the experience in other regions.

The categories of the contest reflected four priorities of “The European plan of actions for the environment and children’s health”: water and sanitary, protection from the injuries and traumas on the roads, improving of the air and protection from chemical agents, and a new nomination – the participation of the youth.

“It’s strange that there were only 6 projects on access to clean water. It means either that a lot of efforts were made, or that we haven’t spread enough information about the contest to the necessary people. There were a lot of project on chemicals impact. The projects from Eastern Europe and also from Russia, Georgia, Armenia justified how much they can do without having enough resources. In fact they probably use resources wisely because they don’t have enough of them. Doing this they prove their professional vision on problems, which are often solved without a support from authorities”, - said Genon Jensen, a representative of one of the contest organizers from the Belgium public organization “The alliance of health and environment”, which credo is “to put the health in the centre of ecological issues”.

The project of the Union of pediatrists from Spain is among the contest winners. They encouraged doctors to help in the campaign for smoking control before the youth begins smoking, “Women for the clean future” from Rumania that provided clear drinking water for children in the villages.

The next contest will be announced in 2009 before the fifth Ministry conference “The Future for our children”.

IS THE GLOBAL WARMING A DESERVED ANSWER OF NATURE TO HUMANITY?

During the break between sessions a lot of discussions were how to make environment safe for the next generation and not only in the framework of the process “The future for our children”. The majority of Ministers, public organizations representatives and the experts of the international organizations feels the responsibility the most sharply, when they have to answer the questions of their own children.

“I have two children: my younger is 15 and elder is 17 years old. They know what I’m engaged in and often ask me: “Daddy, and what will happen in the world?” Especially after the Gore’s movie “An Inconvenient truth” my children asked me for a while – What future is waiting for us? If it looks the same as it’s now, probably we’ll not be able to survive, shall we?

I got used to answer: “We have to work and invest time and experience to change the situation. If to look at the trends without any hope, then the future is very gloomy. There’s a lot to be done. If we seriously understand that the question isn’t only about genetics or other “crazy” things, but the real problems – everything will be changed. My children don’t agree, because they want to have opposite opinion” – answered Roberto Bertollini, the head of the WHO’s program “Environment and health”, on the question what future do you foresee for children.

Global warming brings new threats and challenges for the whole mankind except old and burning problems. Report of Ragendra Pachauri, the Head of Intergovernmental climate change commission at UN, the most prestige commission, that studying climate change, speech was full of sad statistics. To the end of 2020 20% to 30% would be on the verge of extinction only in Africa and 75 up to 250 million people would suffer without clear, safe water.

At the same time children whom contemporaries had assured tough future would suffer the most.

“We had affected the nature in a very unfair way which originated the trouble that is still going on. We have to respect nature in order to be able to control the situation. Next generations have to use natural resources economically and also they have to choose that kind of living so they could minimize affect on the ecosystem.

FROM WORDS TO ACTION

During the closed meeting the head of the WHO Regional office in Europe Marc Danzon shared his biography: “I used to take part in different projects and protest actions for environment improvement starting with my first student year. Probably this is a reason why I occupy such a post now. This true-life example just shows that we have to be extremely active while solving environmental problems. You need to act in order to succeed.”

In 2009 environmental ministers will gathering in Italy for Fifth minister meeting. 20 would pass since such meeting in 1989. This is the age of new generation, which is already suffering from ecological threats. One generation has to report to other one why the environment haven’t improved much for their children. This is also a chance for European journalists not just to highlight this problem once but to force ministers to do their direct job all the time.

P.S. !

On the board I’ve found information in the newspaper “Day’” about presentation of new environmental document “National ecological policy in Ukraine”, where specialists stating the fact that the number of chronic illnesses aroused from unstable ecological situation has gradually increased.

From the other article I’ve found out about President’s intentions to pay 15000 hryvnas for the second child, which he voiced in Kryvyj Rig – the most polluted city in Ukraine. The President presented 13 ambulance cars to doctors in Kryvyj Rig. As Yuri Lyubonenko, the city Meyer, had said in his speech, those cars were bought for the money given after “Kryvorighstal’” was sold. In general 1% of the money was given to the city – about 139,6 million hryvnas. Yuri Lyubonenko informed that money would mainly help to improve the medical provision and to solve ecological problems of the city. In the closest time there would be established diagnostic centre in Kryvyj Rig.

We can build lots of hospitals and medical centers but without resolution of ecological problems that won’t help. We have to change ecological policy cardinally in order to change the present state of things.

day.kiev.ua/183960

-----------------------

[1] See Budapest Declaration and Commitments made at the Fourth WHO European Ministerial Conference on Health and Environment, euro.who.int/document/e83335.pdf.

[2] Chatham House Rules are a UK press convention which states that anything said can be written about, but nothing can be attributed without consent.

[3] Material in this section is drawn from presentations and the monograph WHO (2005), Injuries and Violence in Europe.

[4] Polinder, S et al, A surveillance based assessment of medical costs of injury in Europe: phase 2, Amsterdam, Consumer Safety Institute, 2004.

[5] Sensitivity analysis with estimated average cost of health care from ¬ 1,250 to ¬ 7,250 per fatal Sensitivity analysis with estimated average cost of health care from €1,250 to €7,250 per fatal injury in the Region. Calculated on the basis that there are 800,000 fatalities in Region. (Source: Racioppi et al 2004—see footnote 7).

[6] Sensitivity analysis with estimated average cost of health care from €4,800 to €12,000 per non-fatal injury in the Region. Calculated on the basis that there are 16 million non-fatal injuries in Region. (Source: Racioppi et al 2004—see footnote 7).

[7] Racioppi, F et al, Preventing road traffic injury: a public health perspective for Europe, Copenhagen, WHO Regional Office for Europe, 2004.

[8] Countries of the European Union before 1 May 2004: Austria, Belgium, Denmark, Finland, France, Germany, Greece, Ireland, Italy, Luxembourg, Netherlands, Portugal, Spain, Sweden, United Kingdom.

[9] Sethi, D et al, Injuries and Violence in Europe. Why they matter and what can be done, Copenhagen, WHO Regional Office for Europe, 2005.

[10] Brand, S and Price, R, The economic and social costs of crime, London, Home Office, 2000.

[11] CIS countries: Armenia, Azerbaijan, Belarus, Georgia, Kazakhstan, Kyrgyzstan, Republic of Moldova, Russian Federation, Tajikistan, Turkmenistan, Ukraine, Uzbekistan.

[12] EU countries after 1 May 2004: Austria, Belgium, Czech Republic, Cyprus, Denmark, Estonia, Finland, France, Germany, Greece, Hungary, Ireland, Italy, Latvia, Lithuania, Luxembourg, Malta, Netherlands, Poland, Portugal, Slovakia, Slovenia, Spain, Sweden, United Kingdom.

[13] Information in this section drawn from presentations and monograph WHO, 2005, Health and Climate Change: the “now and how” - A policy action guide.

[14] Intergovernmental Panel on Climate Change (IPCC) Glossary & WHO 2005.

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