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Discussion paper
Prepared by Sonja Tanevska, Zlatko Kovac and Sophia Keri
CONTENTS
Introduction Life expectancy and ageing Disease trends Communicable diseases Non-communicable diseases Health equity MDG Financing of health and social services Water and sanitation Equitable access to water and sanitation Atmosphere and climate Human health Urban health
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FOR INTENRAL USE ONLY Introdution Europe Zone is one of the most developed amongst the IFRC zones. The most of the region is covered by solid transport, communications and public amenities - such as water, electricity, housing and other services infrastructure. Still, a lot of challenges persist, and improved health and social equity are important for the 21st century also. This trend paper, presented by the Health and Social Care Team of the Europe Zone Office of the IFRC, consists of two parts. In the first part, the paper analyses the main trends likely to emerge or continue in the overall health situation of people living in the European region up to 2015. The spread of some communicable diseases in this period is projected to fall back, nevertheless the still high numbers require attention from both the National Societies and Governments affected. At the same time, due to improving access to health services and treatments, non-communicable diseases, mainly caused by unhealthy life conditions or life styles, will gain share amongst the main causes of casualties. The second part of the paper is based on analysis carried out by the WHO, concentrating on health equity, financing of health and social services, water and sanitation, atmosphere and climate and urban health. The last tendencies and changes in these areas within the European region are enumerated, and the projected impacts of these on health of the European citizens are also analysed by the Health and Social Care Team.
Life expectancy and ageing During the 1990s, the average life expectancy of the 870 million people in the European region actually declined for the first time since World War II, largely owing to the deterioration in health status in the NISs1 and some countries in Central and Eastern Europe.
The figures above present the reality of Eastern Europe, while in the Western parts life expectancy is actually increasing and is prolonged. In the EU people live longer lives in better health. Some facts on the demographic situation of the region: By 2030 there will be 34.7 million people over 80 in the EU, in comparison with todays figure of 18.8 million, this shows a rise of 84%; Some countries in Central Asia belong to young countries proportion of people over 60 is low, but trends are changing;
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Fertility and birth rates are decreasing (1.5 children/woman in the EU), therefore it is expected that in 2030 there will be 18 million less children and young people than today; Work force is ageing, number of working people (14 -65) is decreasing rapidly.
Today, people aged 65+ are one of the most vulnerable groups exposed to poverty and social exclusion. According to the Eurostat statistics for 2008, 19% of people aged 65+ were at risk of poverty in the EU27 countries. Across Europe, older women face higher poverty rates than older men, for example in Belgium, 22% of women above the age of 65 are at risk of poverty. These numbers are even higher in some of the Member States: in Ireland one third and in Cyprus more than half of women over the age of 65 are at risk of poverty. The link between disease and age is also crucial from an economic and public policy point of view. In the European countries, the proportion of those aged 65 and older is projected to grow from 15% in 2000 to 23.5% by 2030, whereas the proportion of those aged 80 and over is expected to more than double, increasing from 3% in 2000 to 6.4% in 2030. This trend is clearly one of the most important causes of the growing burden of chronic conditions and diseases. Disease trends In almost all countries of the region, there has been an increase in the health gap between the more and the less advantaged socioeconomic groups. Although the situation varies from country to country, non-communicable and communicable diseases, accidents, mental health problems and complications related to pregnancy and child birth seem to be the major health problems in the region. According to the Murray-Lopez baseline global scenario, a study completed by Prof. Christopher J. L. Murray and Alan D. Lopez PhD in 1996 for the WHO, during the next 20 years the number of deaths caused by communicable diseases will fall (from 34% to 15% globally), and cases of death and disability caused by non-communicable diseases will increase in number. IFRC EZ team, analysed the Murray-Lopez baseline scenario for Europe and Central Asia region, and analysis is presented on the pages bellow. The overall burden of disease is assessed using the disability-adjusted life years (DALYs)2 as indicator.
DALY a time-based measure that combines years of life lost due to premature mortality and years of life lost due to time lived in states of less than full health.
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Fig. 2. Projected trends by DALYs by cause, numbers in (000s), 10 major diseases in Europe, 2015 baseline scenario 16000 14000 12000 10000 8000 6000 4000 2000 0 3,901 1,736 4,349 3,584 1,475 272 1,163 8,331 14,907 HIV/AIDS 14,283 Lower respiratory infections Unipolar depressive disorders Alcohol use disorders Ischaemic heart disease Injuries Tuberculosis Melanoma and other skin cancers Alzheimer and other dementia Drug use disorders
Source: WHO, Health Statistics and health information system, Projections of mortality and burden of disease, 3 2004-2030
When analysing the above graph it is very visible that trends predicted until 2015 can be aligned into the following four groups: 1. Trends showing very high values ischemic heart disease and injuries; 2. Trends showing moderately high values unipolar depressive disorders, alcohol disorders, HIV/AIDS and Alzheimer and other dementia; 3. Trends showing moderately low values drug use disorders, lower respiratory infections and tuberculosis); 4. Trends showing low values melanoma and other skin cancers. The spread of communicable diseases in the region will be focused among key populations. For example, In Eastern part of the region, access to health services and therapy will remain limited, HIV will continue spreading, and will appear as a life threatening disease of PLWH. However, due to the increasing access to health services in Western Europe, HIV is already now considered as a chronic disease. Key population at risk in Western Europe are neglecting preventive measures, contributing to increase of spreading HIV in this part of the region. Tuberculosis will affect mainly people with lower social status, making up to 7% of total deaths and 6% of total DALYs from TB in the world (see figures 3.a. and 3.b.). However, in 2015, throughout Europe, a significant number of the deaths caused by tuberculosis is projected. This means, that the issue of TB infections can not be neglected, since TB would be the cause for more deaths than f.e. drug abuse. Europe is keeping the 4th place when compared with other regions in the World.
Fig. 3a. DALYs caused by Tuberculosis by region, numbers in (000s) and %, 2015 baseline scenario
1,938 9% 6,189 27% 2,733 12% 10,246 44% Africa the Americas Eastern Mediterranean Europe 1,475 6% South-East Asia 503 2% Western Pacific
Source: WHO, Health statistics and health information system, Projections of mortality and burden of disease, 2004-2030
Fig. 3b. Number of deaths caused by Tuberculosis by region, numbers in (000s) and %, 2015 baseline scenario 125 12% 267 27% 389 39% 116 12%
27 3%
Western Pacific
Source: WHO, Health statistics and health information system, Projections of mortality and burden of disease, 2004-2030
Analysing Europe as part of the global picture and comparing Europe to other regions in the world, non-communicable diseases appear to have significant influence on the health of European citizens in the next decade.
DALYs caused by unipolar depressive disorders put Europe in the third place when compared with other regions. Statistically it is in the middle of the graph, however the numbers in trends are still high and require attention.
Fig. 4. DALYs caused by Unipolar depressive disorders by region, numbers in (000s) and %, 2015 baseline scenario 16,381 22% 6,236 8% 12,054 16%
25,077 34%
Eastern Mediterranean 6,699 9% 8,331 11% Europe South-East Asia Western Pacific
DALYs caused by alcohol abuse put Europe in the third place when compared with other regions. Alcohol abuse causes chronic illnesses, such as alcohol dependence, vascular diseases (such as hypertension), cirrhosis and various cancers. Of the global loss of DALYs, 4.7% can be explained by alcohol-related diseases.
Fig. 5. DALYs caused by Alcohol use disorders by region, numbers in (000s) and %, 2015 baseline scenario 1,050 8,686 5,351 4% Africa 35% 22% the Americas 333 Eastern Mediterranean 4,349 1% 4,906 18% 20% Europe South-East Asia Western Pacific World alltogether: 24,675
Source: WHO, Health statistics and Health information system, Projections of mortality and burden of disease, 2004-2030
However, from all deaths caused by alcohol use disorders in the world, 25% are predicted to happen in the European region, placing the region the second place in the world.
Fig. 6. Number of deaths from Alcohol use disorders by region, numbers in (000s) and %, 2015 baseline scenario 4 16 Africa 5% 25 18% Americas 28% 19 Eastern Mediterranean 22 21% Europe 25% South -East Asia 3 3% Western Pacific
World alltogether: 90
Source: WHO, Health statistics and Health information system, Projections of mortality and burden of disease, 2004-2030
When compared with other regions, Europe is ranked second in relation with DALYs due to heart disease.
Figure 7: DALYs from Ischaemic heart disease by region, numbers in (000s) and %, 2015 baseline scenario 4,312 8, 338 7,336 6% 13% Africa 11% 24,472 37% 7,342 11% the Americas Eastern Mediterranean Europe South-East Asia Western Pacific World alltogether: 66,707
Source: WHO, Health statistics and Health information system, Projections of mortality and burden of disease, 2004-2030
14,907 22%
In the next decade, ischemic heart disease will be the main cause of death for European citizens.
Fig. 8. Projected trends of number of deaths by cause, numbers in (000s), 10 major diseases in Europe, 2015 baseline scenario 2500 2000 1500 1000 500 0 638 136 66 212 2 22 31 167 11 2,374 HIV/AIDS Tuberculosis Lower respiratory infections Unipolar depressive disorders Alcohol use disorders Ischaemic heart disease Injuries Melanoma and other skin cancers Alzheimer and other demenita Drug use disorders
Source: WHO, Health statistics and Health information system, Projections of mortality and burden of disease, 2004-2030
2,369 29%
Fig. 9. Number of deaths caused by Ischemic heart disease by region, numbers in (000s) and %, 2015 baseline scenario 1,161 419 1,069 15% 5% 13% Africa 709 9% Americas Eastern Mediterranean Europe 2,374 29% South -East Asia Western Pacific
Source: WHO, Health statistics and Health information system, Projections of mortality and burden of disease, 2004-2030
Among the first 10 risks in European region, injures are also taking a significant place.
Fig. 10. DALYs caused by Injuries by region, numbers in (000s) and %, 2015 28,568 15% 37,164 20% 20,748 11% Africa the Americas Eastern Mediterranean Europe 60,461 33% World alltogether: 184,838
Source: WHO, Health statistics and Health information system, Projections of mortality and burden of disease, 2004-2030
14,283 8%
23,613 13%
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Health equity Persistent problems of poverty and unemployment are exacerbating inequities and in many countries are giving rise to deteriorating lifestyles, increasing violence and weakened social cohesion. Doubts about the quality of health and other services and an imbalance between the demand for and the availability of resources, have alarmed many countries that hard-won social safety nets and benefits may be dismantled. The social conditions, in which people live, exceedingly influence their chances to be healthy. Indeed factors such as poverty, social exclusion and discrimination, poor housing, unhealthy early childhood conditions and low occupational status, are important determinants of most diseases, deaths and health inequalities between and within countries. Even in the high- and middle-income countries of the European region the possibilities for surviving and living a healthy life are still closely related to the socioeconomic background of individuals and families. These possibilities are reflected in substantial and even increasing social inequities in health within countries across Europe. For EU, reducing health inequalities is a central part of a society based as much on the social justice as on economic success. The importance of improving health in general and improving it among low-income groups is a matter of even greater urgency in the countries of central and Eastern Europe and within CIS4. The typical trend in health status, for the population as a whole, in most but not all of these countries is one of stagnation or decline, accompanied by increasing social inequities in health. Two key ethical values in WHO Health 21 Strategy are equity in health and solidarity in action. Equity in health is also stated as core value in 34 out of the 40 national health strategies, in WHO European region. Equity in health implies that, ideally, everyone could attain their full health potential and that no one should be disadvantaged from achieving the potential because of their social position or other socially determined factors. Millennium Development Goals MDGs One challenge for reaching the health and education MDGs relates to equity: uneven access to resources and the exclusion of marginalized groups mean that the benefits associated with progression toward the MDGs are not widely shared by all.5 These inequalities are closely related to quality concerns, because the costs of low-quality education and health care are likely to be disproportionately borne by the poor. Outdoor air pollution increasingly places both children and adults at risk, a problem particularly acute in urban areas of fast-growing economies Inequalities in access to health and educational services exist almost everywhere in the world: the poor tend to be less healthy and less educated than the rich. But income is not the only factor leading to unequal access. So too are differences in ethnicity, gender and social status. In addition, the quality of education and health services is often unequally distributed. Nonetheless, poverty remains the largest roadblock to good health and education and can lead to a vicious cycle of deteriorating health, low demand for education, and increased poverty. The interrelationships among environmental factors, child health, nutrition status, and education are strong and multifaceted, and together significantly influence progress toward
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http://siteresources.worldbank.org/INTGLOMONREP2008/Resources/4737994-1207342962709/059090_GMR08_ch02_web.pdf
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the MDGs.6 Environmental risk factors such as access to water and sanitation play a role in many diseases. It has been estimated that 23% of all deaths are principally attributable to environmental factors. Children are among those most vulnerable and adversely affected. Diarrhoea, malaria and lower respiratory infections are most closely linked to environmental factors. Malnutrition is among the most important determinants of child mortality, together with respiratory infection (largely caused by indoor air pollution), diarrheal diseases (mostly from inadequate water supply, sanitation and hygiene). Financing of health and social services Financial resources are often limited: among the countries of the OECD, for example, public health typically accounts for approximately only 9% of gross domestic product (GDP). This is still a comparatively high percentage when compared to non-OECD countries. In the Republic of Moldova, for example, public sector funding for health decreased by two thirds between 1993 and 2003, when it stood at 3.4% of GDP. The trends are that financing of the health sector will increase, but demands for health services will increase as well.
With the aging of the population, portion of expenditures on social programs for older people will further increase. Globally, at the beginning of the 21st century, aid for health has scaled up dramatically to nearly $17 billion in 2006 (from $6.8 billion in 2000), with support from over 100 traditional and non-traditional entities. Sources include new bilateral programs such as the US PEPFAR, private sources such as the Gates Foundation, and global funds such as GFATM and GAVI.7
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Aid fragmentation more donors with smaller shares of total aid is an emerging issue. OECD DAC data for 61 poor countries and fragile states show that over 60% of countries received aid from 20 or more different donors and over 75% of countries had 10 or more donors together accounting for 10% or less of aid. This makes strong country-led strategies more important than ever. Water and Sanitation Universal access to safe drinking-water and adequate sanitation remains unrealized in many countries in the European region. Infant mortality and morbidity from water-related diseases are on the decline but significant sub-regional inequality remains. This jeopardizes not only the MDG related to environmental sustainability, but also those related to universal primary education, poverty alleviation and maternal and child health. The region is generally on its way to reaching the drinking-water target, although efforts remain vital to ensure access to safe water in the home or dwelling, particularly in rural areas. The sanitation target, however, may well be out of reach for a significant number of countries. Effects of gradual climate change and extreme weather events such as floods and droughts form an additional challenge to the sustainable provision of safe water and adequate sanitation, and to the sustainable functioning of health systems in the region. In 2006, nearly 140 million people (16%) in the Eastern Europe, Caucasus and Central Asia (EECCA) region still did not have a household connection to a drinking-water supply, over 41 million people (5%) did not have access to a safe drinking-water supply and 85 million people (10%) did not have improved sanitation. These general statistics do not reflect important changes in access to safe water and adequate sanitation that have occurred in the European region at the national level. Based on a 2008 review, the WHO-UNICEF Joint Monitoring Programme (JMP) has observed some impressive changes in access to improved sources water and sanitation (UNICEF and WHO, 2008). While the percentage of the population that gained water supply coverage in the period 19902006, compared to the 1998 median population, was relatively modest in the Western part of the region (typically 110%), it was very significant in the eastern part of the region (20% in Azerbaijan). The gains made over the same period with regard to sanitation were, however, more modest, and typically remained below 10% in the countries that participated in the review.
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At present, however, unacceptable levels of, in particular, childhood mortality and significant levels of morbidity from water-related diseases caused by microbial pathogens, chemical contaminants and impaired hygienic conditions persist in many countries. Well known diseases such as hepatitis A, typhoid fever and bacillary dysentery remain a serious health problem for many countries in the region. Equitable access to water and sanitation Access to water and sanitation is often seen as a purely technical problem, while both social and governance aspects are neglected. The criteria for the full enjoyment of the right to water, according to the WHO, are: sufficiency in quantity, safety to human health and organoleptic acceptability, physical accessibility and economic affordability. The affordability of water has a significant influence on the use of water and selection of water sources. Households with the lowest level of access to a safe water supply frequently pay more for their water than do households connected to a piped water system. The high cost of water may force households to use alternative sources of water of poorer quality that represent a greater risk to health. Furthermore, high costs of water may reduce the volume of water used by households, which in turn may influence hygiene practices and increase risks of disease transmission. By way of illustration of the importance of this problem even for European Union countries, it has been reported that in 2008 424,742 consumers in Belgium (approximately 12.13% of population) were in arrears with the payment of their water bills.8 Public understanding of the link between environment, drinking-water and sanitation, and human health is low in general. This is particularly problematic in the event of clear contamination of drinking water, in relation to communication with health care providers, vulnerable populations and consumers at large. In the EECCA region, there is a relatively strong focus on the quantitative, rather than the qualitative, aspects of water resource management. The water and health link is often seen narrowly as securing the necessary amount of water for drinking and hygiene purposes. However, the increasing impacts of climate change are changing perceptions. The relationships between environment, water and health are progressively becoming more prominent and appreciated. Nevertheless, water and health issues do not figure prominently on many governments agendas, despite their high social and economic importance. Special attention is being given to the protection of vulnerable groups, including the growing population of immune-compromised patients, the elderly and the very young. According to the WHO, there is a clear difference between the geographical areas in the burdens of mortality and morbidity attributable to water resource division (WRD) outbreaks within the pan-European region. This factor is directly linked to the access to improved water supply at home in urban and rural areas. For instance, in WHO division of Europe countries on EUR-B9 and EUR-C10 between 10% and 25% of the population in rural areas, and about 80% in urban areas, suffer from poor water supply, in comparison to EUR-A11 countries where 100% of the population in both rural and urban areas enjoy access to water. According to the Federal Hygiene and Epidemiology Centre of Russian Federation, between 2002 and 2008, 41.2% of surface sources of drinking-water and 17.3% of underground
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Anon, 2009
EUR-B: Albania, Armenia, Azerbaijan, Bosnia and Herzegovina, Bulgaria, Georgia, Kyrgyzstan, Montenegro, Poland, Romania, Serbia, Slovakia, Tajikistan, the former Yugoslav Republic of Macedonia, Turkey, Turkmenistan, Uzbekistan. 10 EUR-C: Belarus, Estonia, Hungary, Kazakhstan, Latvia, Lithuania, the Republic of Moldova, the Russian Federation, Ukraine.
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EUR-A: Andorra, Austria, Belgium, Croatia, the Czech Republic, Denmark, Finland, France, Germany, Greece, Iceland, Ireland, Israel, Italy, Luxembourg, Malta, Monaco, the Netherlands, Norway, Portugal, San Marino, Slovenia, Spain, Sweden, Switzerland, the UK.
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sources in the Russian Federation did not comply with national standards of drinking water quality.
Table 1. Percentage of drinking-water sources non-compliant with national sanitary standards, 2002 2008, minimummaximum (mean) and estimated number of people who drink water that does not meet chemical or biological standards
An additional factor for the unequal spread of WRDs is the percentage of the population connected to sanitation facilities. In EUR-B and EUR-C countries, the figure is 1015% in rural areas and 7584% in urban areas, in comparison to EUR-A countries, where 95% of the population in rural areas and 100% in urban areas have access to sanitation. In addition, in both EUR-B and EUR-C countries, only a low percentage of waste water is treated in an adequate and safe manner, which is threatening the environment, especially the quality of water bodies used for drinking-water or recreational purposes. Facts and figures Better management of water and sanitation in the WHO European Region would prevent disease over 30 million cases of water-related disease per year. Worldwide, WHO estimates that around 6% of the global burden of disease is related to water. Infectious diarrhoea is the largest component and accounts for 1.7 million deaths per year: about 70% of the total. Water, sanitation and health intervention typically reduces diarrhoeal diseases by 15 30%, and significantly reduces other diseases. The highest incidence rate of infectious diseases caused by poor drinking-water quality is often found in children aged 611 months, a vulnerable time in life. In this period, water and weaning foods are introduced in the diet, levels of maternal antibodies begin to decline, and the childs immune system is developing; crawling develops and foreign objects are introduced in the mouth. Estimates of the burden of diarrhoeal disease attributable to water, sanitation and hygiene in the European Region for children 014 years of age amount to over 13,000 deaths (5.3% of all deaths in the 014 age group), mostly coming from countries of eastern and South-Eastern Europe and Central Asia. Providing the entire child population of Eastern and South-Eastern Europe and Central Asia with access to regulated water supply and full sanitation coverage with partial treatment for sewage would save about 3,700 lives every year. Atmosphere and climate Projections suggest further increase temperatures in Europe between 1.05.5C by the end of the century, which is in average also higher than projected global warming (1.84.0C). Whether the EU's goal of less than 2C increase (compared to pre-industrial levels) will be exceeded depends on the effectiveness of the international climate policy regarding global greenhouse gas emission reductions. More frequent and more intense hot extremes and a
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decreasing number of cold extremes have occurred during the past 50 years and this trend is projected to continue. Changes in precipitation show more spatially variable trends across Europe. Annual precipitation changes are already exacerbating differences between a wet northern part (an increase of 10 to 40 % during the 20th century) and a dry southern part (a decrease of up to 20% in some parts of Southern Europe). The intensity of precipitation extremes such as heavy rain events has increased in the past 50 years, and these events are projected to become more frequent. Dry periods are projected to increase in length and frequency, especially in Southern Europe. No clear trend in the frequency and intensity of storms has yet been observed, but the strength of the heaviest storms is projected to increase, albeit with slightly lower frequency. Uncertainties for projected annual precipitation and frequency and the intensity of extreme events continue to be larger than those for annual temperature. Climate variability and change have contributed to an increase in ozone concentrations in Central and SouthWestern Europe, which is projected to continue. This may result in current ozone abatement policies becoming less effective. Climate change, including changes in temperature, precipitation, glaciers and snow cover, is intensifying the hydrological cycle. However, other factors such as land-use changes, water management practices and extensive water withdrawals have considerably changed the natural flows of water, making it difficult to detect climate change-induced trends in hydrological variables. In general, annual river flows have been observed to increase in the North and decrease in the South, a difference projected to exacerbate. Strong changes in seasonality are projected, with lower flows in summer and higher flows in winter. As a consequence, droughts and water stress will increase, particularly in the South and in summer. Human health Increased temperatures can have various effects on human health. The large number of additional deaths during the 2003 heat wave (more than 70,000, excess deaths reported in 12 European countries) highlighted the need for adaptation actions, such as heat health action plans. Such heat waves are projected to become much more common later in the century as the climate continues to change, with mortality risk increases by between 0.2 and 5.5% for every 1C increase in temperature above a location specific threshold. The hot summer of 2003 in Europe is estimated to have led to EUR 10 billion of economic losses to farming, livestock and forestry from the combined effects of drought, heat stress and fire. There is some evidence that winter mortality in Europe has decreased, but this could have other causes, particularly improved housing and the prevention of winter infections. Premature deaths, diseases and forced displacement of communities are some of the most threatening consequences. Because of this, there is growing recognition of the link between extreme weather events and health. In the long run however, the greatest health impacts may come not from acute shocks such as natural disasters or epidemics, but from the gradual build-up of pressure on the natural, economic and social systems that sustain health, and are already under stress in many countries in the European region. A number of the vector borne diseases and their appearances will change. The tiger mosquito, a transmitter of a number of viruses, has extended its range in Europe substantially over the past 15 years and is projected to extend even further. Ticks and the associated Lyme disease and tick-borne encephalitis are moving into higher altitudes and latitudes. There is a risk of additional outbreaks of Chikungunya (a virus that is
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highly infective and disabling but not transmissible between people) and a potential for localised dengue to re-appear. Changes in the geographic distribution of the sand fly vector are occurring in several European countries and there is a risk of human Leishmania cases further north. The main impacts of climate change in relation to water and health in the European region are, inter alia: Changing precipitation patterns, with increased water scarcity in the Southern areas and increased water availability in the Northern latitudes; Change in precipitation extremes in both intensity and frequency, with higher flood risks and associated mortality, physical injuries, infectious disease and psychological trauma; Reduced water availability, resulting in higher concentration of pollutants, and higher water temperatures, resulting in more intense growth of micro-organisms, including pathogens; Projected further rises in lake and river surface water temperatures with increasing air temperatures, which will have several effects on water quality and hence on human use of aquatic ecosystems. Secondary effects include: Changes in water quantity and quality resulting from climate change that are expected to affect food production and availability; this is likely to increase the vulnerability of marginalized groups, such as the poor, women, children and the elderly; Impacts of climate change on the functioning and operation of existing water infrastructures; Water resource management impacts on many other policy areas, e.g. energy, health, food security and ecosystem functioning. Generally, to reduce the consequences in an effective way, adaption to climate change needs to be integrated into national and local health strategies and plans; and preferably to be included into other sectors of national and regional policies. The principle of target setting means that coordination mechanisms must be established and a baseline analysis carried out for each specific topic before specific targets are set. Urban health Two thirds of the population of the European region live in towns and cities. Urban areas are often unhealthy places to live, characterized by heavy traffic, pollution, noise, violence and social isolation for elderly people and young families. People in towns and cities experience increased rates of non-communicable disease, injuries, and alcohol and substance abuse, with the poor typically exposed to the worst environments. Several epidemiological studies have identified the elderly and subjects with a pre-existing chronic cardiac or respiratory disease, congestive heart failure, and diabetes as subgroups more sensitive to the harmful effects of air pollution than the general population. This is also the case for children that may experience greater health effects due to the special sensitivity of their developing biological systems.
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