On the way to Parma: understanding and addressing the influence that social inequities have on environmental health

On 10–12 March 2010, ministers of environment and health of the 53 countries in the WHO European Region (and a number of international governmental and non-governmental organizations) will meet in Parma, Italy, on the occasion of the Fifth Ministerial Conference on Environment and Health. One major item in their agenda is going to be the increasing challenge of inequities in exposure to environmental hazards. These inequities emerge both between and within countries, and are significantly influenced by social conditions.1 The recent economic crisis has further exposed the potential exacerbating effect that social factors may have on inequities and their consequences for health.2 To support its Member States in developing more informed policies on the environmental dimension of health inequities, WHO commissioned evidence reviews on the occurrence and extent of social inequities in exposure to selected environmental risk factors with a specific focus on inequities affecting children.3 Social factors considered in these reviews were socioeconomic status (income, education, employment), age, gender, ethnicity, or being part of a minority group. Summaries of the reviews on social inequities in housing4, waste management5, air pollution6 and children's environment7 are published in this issue of the EJPH. The compiled evidence was reviewed by 40 experts from 20 countries at a consultation meeting convened by WHO in Bonn on 9–10 September, 2009, resulting in a set of policy recommendations on possible measures to be undertaken to alleviate the inequities and their health burden. The reviewed evidence indicates that social and particularly socio-economic factors are predictors of exposure to all covered environmental risk factors. In most cases, the socially disadvantaged groups bear the greatest burden of environmental exposures. Some studies also demonstrate that inadequate socio-economic conditions may increase vulnerability of the exposed individuals. These gradients are evident across social strata in all countries where research has taken place, and there appears to be a trend towards growing segregation and widening social disparities. Health impacts related to the combined environmental and social risks are documented in some countries, but the number of relevant studies is low. Marginalized and disadvantaged groups may be disproportionately exposed and vulnerable to environmental risks through a range of mechanisms including limited financial resources facilitating risk reduction, hazardous or unprotected work, or poor and unsafe living conditions worsened by social segregation and stigma. The wide variation in the nature of inequities both within but particularly between countries, and an evidence base limited to only a few countries of the WHO European Region, make it unrealistic to formulate policy recommendations that can equally be applied to all countries within the WHO European Region. Thus, with the present status of knowledge, the focus of the recommendations needs to remain at the strategic level, while more detailed responses need to be formulated at the national and/or local level. Disadvantaged groups are likely to benefit most from equitable interventions to provide a safe and healthy environment for all; however, the extent of the inequities suggests that targeted action, based on identification of the groups with highest risk and combined with political commitment to reduce the inequities, should be pursued in the policy agenda at local, national and international level. In many situations, those most exposed and vulnerable to environmental hazards are least culpable for production of the hazard. Governments need to take the lead in formulating relevant policies as the disadvantaged groups are least likely to be in a position to influence the necessary policy change. This calls for commitments not only by health and equity advocates but also by non-health stakeholders from other sectors (e.g. social, environmental, transport, housing and territorial planning sectors). But what can national governments do to tackle and reduce the impact of social inequities on environmental risk and health? Formulating guidance, based on what works, is not easy: case studies on successful action and intervention studies tackling inequities are not abundant. However, the compiled evidence suggests some principles and characteristics of successful policies that national action should consider to incorporate. Countries seeking countermeasures to mitigate social and environmental inequities must take into account the driving forces and root causes behind these inequities. However, it is clear that there are no shortcuts to undo these inequities, product of decades of social mechanisms. A successful strategy must thus distinguish between short- and long-term objectives. In the short to medium term, action must be taken to reduce the connection between social inequities and health impacts of environmental hazards. The policies should specifically focus on equity and prioritize exposure reduction and prevention of their impacts in the most disadvantaged groups. This requires identifying and mapping these population subgroups in any given national context. In the medium to long term, governments need to focus on actions to reduce, stop and reverse the trends that generate inequities in environment and health by addressing their root causes. Not surprisingly, progress recently made in the understanding of social determinants of health fully applies in the environmental domain. In consequence, the three overarching recommendations from the report of the WHO Commission on Social Determinants of Health should also form the backbone of any governmental action to reduce social inequities in environmental health risks: improve daily living conditions; tackle the inequitable distribution of power, money and resources; measure and understand the problem and assess the impact of action. To reduce environmental inequity, health equity and environmental justice should be an integral part of environmental health governance and territorial planning systems. This calls for an increased integration of health equity and health impact assessment elements into statutory planning processes, and the provision of data that enables the identification of environmental risks in relation to social determinants. National health systems need to recognize that not all inequities will be mitigated or prevented and this will inevitably lead to a higher disease burden in disadvantaged population groups. Adequate primary health care services and infrastructure should therefore be considered an essential component of preventing, addressing and reducing social inequities in environmental health outcomes and need to be further strengthened. In addition, investments into national environmental surveillance systems and environmental protection measures may have a similar benefit for population health. For any government, limited data on exposure to environmental risks—and especially the lack of data stratification by social determinants—should be a reason of concern, and a component of environmental inequity in itself. Therefore, governments as well as regional and local authorities should initiate and maintain monitoring systems enabling the assessment of the role of social determinants in environmental risk and the identification of the most vulnerable population groups. The research on health impacts of environmental exposures should enable identification of the socially determined heterogeneity of risks within society, guiding effective and equitable risk reduction policies. However, the lack of data on risk groups should not be used as an excuse for inaction. Available technology and information should be used to provide safe and healthy environments to the whole population. Ultimately, primary prevention approaches, covering also socially disadvantaged groups, are likely to provide more sustainable and equitable use of resources compared to remediating, at a later stage, the health consequences of social and environmental inequities. The WHO expert meeting ‘Environment and health risks: the influence and effects of social inequities’ was supported by the German Ministry of the Environment. Conflicts of interest: None declared. The authors acknowledge the contributions by the authors of the background papers and the meeting participants.