text:
Mayo Clinic
BATCo document for Mayo Clinic 27 March 02 BATCo document for Mayo Clinic 27 March 02 ENVIRONMENT
Date: No date
Length: 131 pages
Jump To Images
Length: 131 pages
Jump To Images
- Box
- 3900
Document Images
Page 1: 39000936
BATCo document for Mayo Clinic 27 March 02
Page 2: 39000936
BATCo document for Mayo Clinic 27 March 02
Page 3: 39000936
ENVIRONMENT AND HEALTH IN CENTRAL AND EASTERN EUR.OPE CLYDE H ERTZMAN WITH CONTRIBUTIONS BY ZOLTAN ANNAU. WENDY AYRES. GOR.DON HUGHES, MICHAL KP~ZYZANOWSKI, AND BAR.R.Y LEVY A I~EPOR.T FOR THE ENVIRONMENTAL ACTION PROGRAMME FOR, CENTRAL AND EASTERN EUROPE THE WORLD BANK . WASHINGTON. D.C. BATCo document for Mayo Clinic 27 March 02
Page 4: 39000936
Table of Contents Pzeface ' ~ii F.~ecutive Summary introduction The Determinants of Health in Central and Eastern Em'ope 2 The evolution of the East-West I/re expectancy gap 2 A new approach to analyzing the life expectancy gap Conceptual and accounting ~ramework 3 Competing explanations for the current life expectancy gap 5 The historical long wave The contribution of the chemical and physical environment 5 Health care and the economy 9 The contribution or'individual lifestyle factors /0 The contribution of the social, political, and economic environment A reappraisal of the determinants of health in Central and Eastern Europe 15 Health and Environmental Pollution 16 Methods of data evaluation 17 The geography of environmental health conditions in the region A re~ional hot spot--the mining district= of Northern BohemL~, Czech Republic A town at the confluence of point sources of pullut/on--Copsa Mica, Rom~nta "Bad town planning'--D/mitrovgrad. Bulgaria Health problems assodated with the pdmdpal envLmnment,d exposm-es in the ~*~ion 20 Exposure to lead 20 Respirato~ conditions and other problems associated with air pollution 25 Other environmental health problems in the reg/on Axsenlc ~ drinking water 42 Infectious disease and rrdcrobio]ogtcagy contaminated water Problems unique to specific lcx:ations 46 Environmental conditions of speda] concern to human health, but for which no health data exist Contaminants in food 49 Hum~ Health and the Envi~nmental Aelion Prggramme for Cent~ ~nd F.~ttm E~ope 5t Economic transform,,tion and envL-onmenta] health 52 Priority ~vestments and health 53 dL,~,~do~ of Rl~ Aek~ Ctyde H c,~n is sa~ A~x~t~ Pmf~sso~ in the Det~s~nent of Health Csre ~ Epldemlo~o~,, Y-aca/t~ of Medicine at the Univ~sity of Bdtlsh Columbia. He is tlJo a Pellow of the Pmg~ams in Population H,.,.Ith ~nd Hum~ [X.ve]opm~t in th~ CLna~ Ln.stitute for Advanced Rese~:h. m BATCo document for Mayo Clinic 27 March 02
Page 5: 39000936
Othe~ st~ate~c considera flons ~ The need for remedialion-odented health data 57 1 2 4 59 Separath~g fact ~mm fiction: collecting and evaluating environmental health ln~ormaHon 61 Temporal trends in ~e e~pectanc~ Temporal t~ends in in~nt mortaltC?j Sumn~ry o~ hUnCh health problems and m~or industr~l plan~ located in pollution in Bulgaria, Czech ~nd $1ov~k Relmblic~, Htm~ry, Poland, Rotunda, Larva, Lithuania, F.stonla, Belarus, Ukraine, and Eusopean Russi~ 73 Heavy metal contamination: seleded data 91 Ambient ~ m~d water quality: selected data 93 Health status in relation to environme~tal pollution: selected dat~ PCB food contamivation in the S[ovak Republic I01 Places where more in(ormation is needed /03 Occupational health 105 Biblio~aphy /I3 99 3.1 Chernobyl 37 3.2 Environment and health in Russia ~4 4.1 Airborne dust or gasea--wb]ch is moR important? 52 4.2 Enviro~'~mental improvements in the non-fer~us metals industry--Plovdiv and Copaa Mica 4.3 Cost-effective ways to control emissions horn transportation sources 55 4.4 Environmental investments in the iron and ste~l industry 55 4,5 Investments to control emissions from coal burning 56 Text Tables ZI The emerging gap in life exl:~'tanc~ after age thirty ~ Hbtod~l evolu~on of ~e ex~n~ ~ F~and and ~ 7 2~ Evolution of ~e ex~n~ ~ ~e ~h and Slovak g~bH~ by pm~ 7 2.4 Rela~ve ~ of n~l p~ble~ ~ db~ of ~ Cz~ Re~b~c ~ by a~ ~Hu~on 8 ~ ~todc ~ng~ ~ avenge a~ual s~ dio~de ~c~o~ 8 2.6 M~i~Hy avoidable death rat~ 2.7 Tem~l ~n~ ~ agPs~c ~iova~r mo~ ~t~ Z8 ~ant mo~a~ ~t~ ~ Poland ~ ~on to mo~'s ~ l~el of ~u~on a~, 1987 2.9 Ag~s~c d~th ~t~ (~ 1~,~) ~ level of~u~on ~ ~e ~ Re~b~c, 19~1982 73 3.1 Meal ~ntent of ~te~b ~ for ~g ~ ~ Pond 20 3.2 ~o~ent ga~e~ n~r ~t ~ o~ m~b, Pond 33 DaVy m~I ~ ~m f~ ~ PoOh adolph,, 1~ 3.4 ~ lead ]eveb ~ ~ con~t~ a~ ~ ~to~ 21 ~.5 BI~ lead ~ ~]d~ and mp&~ ~ vaH~ p~ ~ ~e ~to~ ~on, 1989 3.6 Bl~ lead leveb among ~d~n ~ ~b~, ~to~ce 22 3.7 I.Q.s of ~d~ ~ d~nt bl~ l~d 1~, ~t~ 3.8 BI~ l~d leveb among ¢~d~ ~ H~ 3.9 ~d~n's bl~ lead leveb ~ ~e a~ of ~ov~v ~d ~ov~ad, B~g~ 24 3.11 ~Hc ~ng~ ~ av~e a~! ~ dio~de ~n~o~ ~ ~e ~ ~d ~o~ R~bH~ 3.12 S~ dio~de ~ncen~flo~ and ~p~ d~ ~ Poiand~ 1~2 3.13 ~dd~ce of cong~ anode, UI~ ~d ~ ~1 29 3.15 ~o~ ~on a~ng ~d~ ~ ~v~d, B~ 3.16 ~l~on of ~dRn'l d~elo~ s~ ~ ~d, g~g~ 32 3.17 Mo~ ~ ~ com~ ~ ~ ~ a whole, 1~ 35 3.19 5~d~ ~dd~ ~ for ~ ~ ~ ~ R~b~c 39 12 26 BATCo document for Mayo Clinic 27 March 02
Page 6: 39000936
3.21 Wste~- supplies not meetinS microbiological and ~e~! s~, ~ ~ Mu~s~c u~ amons ~d~ ~ ~t~i~ ~, 1987 ~ 3~4 ~ quafi~ ~ ~thua~a ~ Text Fib'ares 2.1 Model for lnvestigat4.ng heter~gene~ties h't PolmLttion heal~ atatu~ 4 3.1 Effect otr nature school on ~piratory, immune, and hematological parameters among ~ children from Polluted parts cf central Bohemia 30 -~.2 Incidence of digestive tract cancer~ in rele~ion to nltxate in drink~g water in seven areas of Bon.od County, Hm~gary ~ 3.3 Mortality by minL~g and non-mining districts of no,bern Ik~hemia, 1983-87 Text Maps 3.1 Dtstrict~ of the former Czechoslovakia by the pe~.-'entage of residents living in areas with the highest levels of air pollution 3~. Female life expectancy by district, 1981--85 Annex Tablet A4,1 Ma~or induatrlal plants located in poI1u~ion "ho~-spo~" ~,I ~ad and ~d~um ~ ~t~ ~ ~1~ i~ ~ Pond 9I A5.2 ~d and ~d~ ~ gaMen plo~ ~ ~to~ce ~.3 Meal ~n~on ~ f~ ~ the ~ and Slov~ Repub~: ~br~ and ~ ~.4 ~ad ~n~fion o~ f~ ~ ~ Plovdiv/~ov~d, B~8~, 1~/91 92 ~.5 ~ad ~nc~o~ ~ ~ir and b]~ ~ Esto~ 92 A6A ~bi~t a~ quall~ ~ se]~ }~a~ ~ Cen~al and ~ste~ E~ 93 A6.2 ~fio~ of to~ ~ PoUnd (not ~dud~g ~to~ce) a~g Io ~bi~t A6~ ~ qua~ ~t~ 5 ~omete~ o[ fe~er p~t, Jo~va, Mth~ 96 A6.4 M~n ~n~n~a~on of air ~Hu~n~ by db~n~ ~m ~eter of ~d~ ~ne ~ ~mzhye, ~a~e 96 A6.5 Avenge a~na] ambient ~n~n~a~om of poHu~n~ ~ ~to~ce ~, Po~d, 19~ 97 A6.6 ~dl~tor vola~e a~ ~ ~e a~ Vac, Hungaw, ~m~ ~ ~1~ ~n dfl~ 97 A6.7 Pollu~n~ ~ ra~water, Teplice, ~h Republic, 1989 A6.8 Metal ~ncen~o~ ~ d~g water, Cz~ Repub~c, 19~ A7.1 Re~tive p~valen~ of ~c b~n~ ~ ~k6w, PoUnd 99 AT~ Na~ ~h~l and he~tolo~i ~on ~ ~d~n ~m no~em ~h~, ~ ~bBc 99 AT~ ~valence of health pmbl~ among c~d~n: ~ Re~b~c ~m~ ~ ~8 d~ A7.4 ~va]e~ of anent ~ Eaton: ~dus~] d~ comp~ ~ T~ A7.5 ~ ~Hu~on and abhor! p~ ~ ~e: ~o ~d~ ~fi~ mm~ ~ ~L 1981~ A7.6 ~s in fat ~sue ~ auto~y ~mp]~ ~m ~e S]ovak Republic A7.7 ~at~ n~r of worke~ e~ to tome agen~ at work at lever a~ve ~e allowable con~n~o~ A10.1 U~ lead leveh at the ~ p~nt, Cop~ ~, RoSa, 19~ AIO.2 ~ual ~dd~ce ~te of ~flo~l d~ ~ PoUnd, 19~ 107" A10.4 Most ~o~y ~ ~pafio~I d~ ~ ~, 1~ ~id~, and ~n~oR I10 . AI0.6 ~on of com~t~ ~pa~6~l'd~ ~ B~ga~, t9~ 100 Annex l:lsuret A2.1 T~po~ trends tn ]//e expectancy--m~les ~0 A2.2 Temporal t~ends in life expectancy--temak, s 70 . A~.I T~poral ~ds 1. ~'~nt mortal~ty~l~s 72 A3.2 Temporal trends In infant mortality--females 72 BATCo document for Mayo Clinic 27 March 02
Page 7: 39000936
Preface The nature of the problems that we ascribe to envlronmen- tal l~oUution, their intensity as threats to pubUe health, and the methods we use to evaluate them and set priorities have all changed dramatically over the last 40 years. Threats to human health f~om environmental pollution have come in ~ classes whose r~ognition has followed one another over time. The ~rst class might be called tradi- tional occupational diseases. "]'his includes si]icnsis, $lli- cotuberculosis, acute lead poisonln8, and oth~ syndromes which have been recol~'~ized to Ix associated with high dose exposures at work for several centuries. The second class might be called epldemiologically detectable risks. These ar~ the problems which began to receive attention in the 1960s snc11970s, in the wake of the recognition of the relationship between ciga~e smoking and lung cancer. They include lhe whole fancily of occupa- lional and environmental cancers, sensitivity syndromes (for example, chemically i~duced astl~a), nes.m:~behav- total syndromes, etc., which require the methods chronic disease ep|demlology to detect because they are usually r~]ated to long-term, low dose exposures. The Enal class might be called the sub-epidemiologic Hsks. These relate to problems, such as chemically induced cance~s and allergic sensitivity syndromes, which might I~ doe to non-threshold l:n~cesses. Sub-epidemiologic risks raight also ari.~ ~ l~'Oblems which l:~r~in to Sl:~ cial l~pulations (such as those living near toxic waste sites) which m~ght be exposed at very low doae~. In othe~ words, the concern here is focused on potative risk ocposures to industrial chemicals at do~s ~o low to le~d to epldemlologically de~ectahie inc~ases in dlsea~e rates. Concerns n~,garding thi~ l~ilel- class of throat to human health have developed more ~ecently than .the prevlou~ classes. The sul>epldemiol~ic risks have r~atly ~ome to the t'orefmnt of environmental health in North America, but tl~ i.~ not the sltuatlon in Central end Easi~,rn (CEE). When the lxRltical changes sl~uck, the ~'Sion was stlJ] in an era in which epldemlologlcally delectable risks had not yet been ~'og'rdzed and addressed. Moreover, the ira/fable evidence f~m environmen~l and public health ~(mn:es strongly impEed that ~ ~e ~ ho~ ~, ~ old ~ a~s. and ~ ~~ w~ w~ l~t~ ~ cl~ to ~t ~ of ~u~o~ ~e~ w~, ~, ~ide~olo~ca~y det~ble ~, up to ~d ~u~8 ~ of mo~W. ~ ~ an ~t m~ol~ qu~on: ff it ~ ~e ~t the m~ ~d ~temi~ of ~e ~en~l h~lth p~ble~ ~ C~I ~d ~st~ E~ t~ay a~ s~r to ~ ~m a p~o~ e~ ~ W~ ~d No~ ~e~, would the most app~p~te m~s o~ ~alua~on and pHoH~g ~ on~ ~fly ~ ~r ~e I~d~g ~ge p~hie~ of advan~ ~d~l ~- ~? ~ vol~e ~ ~ on ~e p~dple ~t ~e ~I- ~ and p~o~g p~ should ~ ~o~ to ~e s~aI f~ of ~e ~en~ si~a~on ~ ~e ~on. ~ Cen~ ~d ~stem E~, ~ m~ ~- ~g ~lh a ~a~ ~r a rough di~g ~e ~ epi- d~olo~y d~ble ~ ~d ~Ide~ol~c ~, and ~Hng p~oH~ to ~e foyer. A d~ of ~ d~t ~d ~ app~ it was ~ at ~gh-leve] m~8 of h~ ~d en~- Co~gen, ~rk ~ ~ ~3. ~e m~g wa~ ~ ~ ~e World H~th ~on, ~ U~ BATCo document for Mayo Clinic 27 March 02
Page 8: 39000936
BASIC FIGURES FOR COtJNTRIE$ IN ~ENTRAL AND EASTERN EUROPE 0,05 3,250 115 36 5 L4 n~ 32 N~J~rl~nds 373 0.07 1~,1~0 404 ~9 37~ 47.6 21 BATCo document for Mayo Clinic 27 March 02
Page 9: 39000936
Executive Summary Intreducffon The purpose of this ~ort is to evaluate the influence of envi~nmental pollution on human health in comparison with other dete~nts of health in Central and ~astem Eu~pe: to summarize current knowledge about locations in Central and Eastern Europe where environmental lution has influenced human health; and to identify the F~ncipal ~Ves of environmental exposure which affecting human health and could be subject to remedla- tion Ihrough concerted environmental action. In general, there have been few weD-designed studies of the effects of environmental pollution on human health, so lhat envL-onmental exposures have been inadequately characterized. The people of Cenh'al and Eastern Europe (CEE) have had to contend not only with environmental problems, but also with many other threats to their health, from social conditions, behavioral and lifestyle factors, and shortcomings in medical care. ~xtle env~onmental exlx~u~ is not the only threat to health in the region, the evidence suggests that health damage due to pollution significant. The Determln~nls of Health What has been the relative contribution of environmental pollution to human health in Central and Eastern Europe? One approach to answering this question is to trace the causes of the widening ~e expectancy gap between coun- tries of Central and ~astem Eu~opo and Orga.nisatlon for Economic Co-operation and Development (OECD) court. hies over the past three decades. The evolution of Hie expectancy in ~ counhies has undergone two phases. Until the mid-l~Os, rapidly der2ining in/ant mortality rates led to a near convergence of ~st-West [~fe ex~sectancy~ Since the mid-1960s, ~ expectancy in the counhies of Central and Eastern Etuvpo h~q ~allen behind Western Eu~i~, North A~erica and Japan by a~roximately 3 years. Life ~.'pectancy in the OI:CD c~.mtries has continued to rl.~, while in tEE coun- laies ~e-expectancy has remained static or even declined. This gap is prlmarlly at~butable to differences in mortal- ity ~rom clu~nlc diseases in mld-llfe. However, the reasons for these dl~erences are not yet dear. The explanation must involve some combination o! factors in the socio-eco- hondo and physical envlronmen~s, behavior patterns and social hab/ts such as smoking and diet, and di£ferences in The analysis shows that the impact of environmental pollution on health in Central and Eastern Europe has not been as dramatic as some popnla.r journalistic descriptions would suggest. Instead, environmental pollution can be seen in context as one of a series of competing determ/- nants of health. On average, the relative impact of environ- mental pollution on life expectancy in heavily polluted areas of Central and Eastern Europe turns out to be no mo~ important than shortcomings of medical care and De style factor~ such as diet, smoking and exercise. On the othe~ hand, ~viwnmental pollution is clearly damagin8 health. ~ expectancies in tufa] areas in Poland have surpassed tho~e in urban a~eas in recent years, a highly unusual demographic tnmd which is associated with the ~ct that envimnmenta] ]:>ollution is concentrated in ruben a~.as. In the Czech Republic, tha~ is good evidence that dust and ~ dioxide pollution increase the risk of infant mortality. Moreover, Hie expectancy in the Czech lk.publ~c is lower in regions affected by heavy' air pollution. Recent evidence from studies done in the West will allow us to estimate the impact of respirable dust o~ overall mor~- ity in Centnd and Eastern Europe. Prellmina~ estimates chow that the effect is likely to be substantial. HeaJth and F..nvL-unmental Pollution Data from twelve countries in Central and Eastern Eurcrpo have been ~ to tentatively Ident~ loc=tions where people are exposed to specific hea2th risks from particular kinds of pollution, {The spocHic locations ~ described in Annex 4.) The most common h~alth p~blems are the result of ex]xeures to a fttrly rim-row ranse ol poUutants: • Lead in Air and $oJ7. If children are overexposed to lead, their mental development may be ~.ax, ded, with BATCo document for Mayo Clinic 27 March 02
Page 10: 39000936
long-term effects on their educational atiairm~ent. Lead pollution comes mainly from Indus~'ies such as lead m~d zinc smelters. People tiv~g near main roads may be affected by le~d ~'rom vehicle exhaust~. • Airborne Dust. This may cause acute and cbxonic res- piratory conditions, such as sinusit~, pha~msitis, bron- chitis, cunj~nctivitis, and asthma. Exposure to dusts and other gase~ may aL,~ cause lung cancer and abnormal physiological development. D~t comes from bun~n8 coal In hou~hold barn~ces, small enterprises, power and heat plants, tnd metal/urgical industries. In some of the worst af-fecied places, high concentrations of s~.~pended particulates are combined with high levels of sul~ar diox- ide. AI/coun~es for which data were reviewed have places with high cadn~um emissions caused by enersy combustion and emissions ~rom the nowferrous metal Industry. • Sulfur Dioxide and other C~. These come mainly from power and industrial plants, as well as households ~Ln8 hi8h'sulfur coal or high-sulfur ~e] oil (3 percent sulfur) typically imported from Russia. In the longer term, transportation will con~b.~te sigr~i~cantly to emis- sions of nitrogen oxides. Poilutant~ in food and water have rome effect on health, but are on average less prevalent and/or less dearly ~ated to ill health than lead, dust and airborne 8a~es. The most important contaminants In food and water in Can~'al e~d Eastern Europe are~. • Ni|raf~ in Drinking W~trr from inadequately main- tained/desisned or improperly located rural septic tank~, feed lots and agricultural enterprL~es, and inappro- p~ate fertilizer application. • Con~min~mts ~n Food/n~m the inappropriate handling or disposal of teed dust, heavy metals, pesticides, polycyclic awr~atic hydrocad~, a~d chlor~ated ors~mica such as PC]~. Iv~ny of the~e s~bsmnces have w~.documented toxic properties, yet the human health significance of inges- ~on at la~ely unknown doses is uncertain. • Other Contaminants in Water ~rom the inappropriate handing or disposal of water contaminated with a~seni¢, vlr~ses/bacteria, pesticides, radionudide~, and chlori- nated organics. Waterborne arsenic and viruses or bacte- ria have been dirtily implicated in a number of episodes of human disease in the region. The other contaminants, like their counterparts in food, represent risks of unknown prevalence, magnitude, and certainty. In asse~ing the most important hea]th problem~ from pollution, the lollowing considerat~ons apply: • Dust versus Eases. The impact of respirable dust on mortality (in addition to its role in respiratory morbidity) is being re~os~zed from st~dies of a vartel7 of major urban center~ in the West where ambient dust concentra- tions are much lower than in many places in Central and Eastern Europe. The list of place,, in the region with human health problems asu~iated with air pollution include some where the primary problem is dust; rome where it is one or more 8a~es or vapors: and many where the problem ls a combination of the two. • Air versus Water. A~rborne pollution ls almost cer- tainly a ~reater tkreat to human health than waterborne pollution in Central and Eastern Europe. Polluted air is harder to avoid than polluted water. "Fnu~, any country wh/ch has zones where ambient air quality could a/feet human health tends to have evidence that it has a~focted health, and the more people who llve in the zone, the greater the public health sign~cance of poor air quality. For water pollution, tartar settlements tend to have more re~ource,J available to replace polluted surface water with deep ground water and to treat trdcrohiologlcaliy con- laminated rources with coagulation and ch]orinstion. The sit~ation in rural azeas is somewhat different. [n the countryside tha only altenmtive to surface water will usually be shallow ground water, which is vulnerable to nitrate contamination. • D~,ilion ofPollut~nt Ca~e&odes. Some of the expo- sure categories which have been u~ed here may seem very broad, at least from the perspective of exposure assessment and epidemlologi¢ toxicology. This is because they repr~ent a compromise between a desire to come to terms with the rich knowledge base of environmental health, on the one hand, and the necessity of using expo- sure ~ategories which are practical from the perspective of remediation, on the other hand. F.nviromnental Investment Priorities to Protect Human Health Because r~ources for environmental improvement are scarce in Central and Eastern Europo, it is ne~e~ary to set priorities which reject the urgency and importance of envi- ronmen~al concerns. The damage to ho.man health due to exposure to envirvnmenta] pollution is the first environ- mental concern in the region. Evidence from selected OECD countries sugges~ that the cost~ of d~unage to h~lth due to poor envlronmen~al quality almost certainly outweigh the costs of damage to physic~l or ~atural capital. Investments, pollcles, and institutional actions which will effectively reduce or eliminate specific enviroru'nentsl exposures will have a positive impact on human health. Furthermore, the potent~l benefits of reducing health problema such as neurobehavinral dysfunction due to lead overexposure and acute and chronic respiratory problems ~scciated with dusts ~nd gases wi~ likely have positive economic impacts in addition to meetLng social and hun~r~taHan objectives. Market reform, Industrial ~structuring, and environ- mental Incentives and regulations ~hould gradually eddres~ a la~e part of the emissions causing the most seri- ous health damage in the region. Projections of the ~evels of reduction in emlsslons for each ma~or air pollutant have ~ made for (relatively) high and low emi~ion coun- ~es in the ~,ion, based on alternative reform scenarios. In many countries, total en-d.~lons o| particulates and su]- htr dioxide are expected to decline by 70 percent or more In the period ~990-2005, even ff their Gro~s Domestic Prod- uct recovers to pre-reform levels. Declines o~ S(} percent or more In other air pollutants such as nil~ogen oxides and airborne lead are ILkely. However, In order to sustain these declines over time, and to achieve them in countries where rome pollution levels are very h~gh to beg-in with (espe- CD BATCo document for Mayo Clinic 27 March 02
Page 11: 39000936
daily in the forme~ .qov/e~ Union), pubL~ invmtment will be ~equlred to speed up the pregtss of Improvement or to address envimnmenlal problems which ~ persist in spite of the transition to • market economy. New investment is only one part of the way that eco- ment. Ind,~-~d it may n,~ even be the ~ Impc¢~-~ simply by ensuring that plant and equipment k properly specification, and that b_aks and spiRs are prmnl~y dealt with. Lq lzz~e Fart this is a matter of commiUnent to and pride in achieving • bettm- env/mnmental necord. Thus, ~'iv- ial but ~/mbolic steps such as imbl/cizing the achievement of plan~s or work groups which mak~ s/gn~cant e~v/rorr. mental iml~vements can produce sm'prislngly large ~ fits. It k,llows that investments must be reinfomed by expenditures on management and worker training and othe~ pn:~nms to ensure they ~ the best Ixaslble Immediate Pr~'~.for F.nvimnng.atal In~sbrg, n~ The immediate priorities for environmental invesunen~ to protect health are: • The Instalhfion of dust collection systems and ~ters to non.k-rams metal ameRer~ which are located, within 5 Id]ometer~ upwind of significant centers of popu- latlon, Priorit~ should, in particular, be g~ven to lead, zinc, ~pper and aluminum plan~. In the ]onger tem~ pollution • batement strategies should be developed to reduce lead emissions ~rom u'ar~port • The install•t/on of equipment to ~duce em/asions of dust, smoke and soot, •nd carbon monoxide from ~ ptan~s, c~mmerdal promises and households in those towns and cities where the average ambient concentra- tion ot particulates during the winter month~ exce~ 150 • A~i~lance to ~cil~ta~e the l~pe~ in~alla~on of d~neatle ,el~Ic tt~s and the •p1~pt~te dlalxml of manure firm intensive llveslx~c.k operatiom in rural areas where levek og rdtrates in drinking water drawn 'fram ~allow wells typically exceed 10 m11/israma of niWate-N institutional sctions to reduce health damage ~om pollu- tion ~ mqutre relkble dala on envlnnunental condltlons and health outcomes. In the •hofl term, priority ~muld be siren to collet~ng and evaluat~g data on the ef~c~ve- hess of(s) reducing exposures to kad; Co) reducing threa~s to respiratory health, and (c) controtling morbidity and Note I. The proposed thre~old I~ ba~d ¢n the ~endard WHO publk: dsinklng wst~r. The thnmhold sll~ws a ~dm'ab~ marg/n of ~dety ~o that a less |trk'i threshold of 20 m[~/l of n/trate-N would prevent almo~ all ~ of me~hemoslobtne- ~ not ~ceed .~0 mS/! of NO,~ wh/ch t~ equlv~Jmt to 11 rag/! of ~ltrat~-N. BATCo document for Mayo Clinic 27 March 02
Page 12: 39000936
ECONOMIC INDICATORS FOR COUNTKIES OF CENTRAL AND F.ASTERN EUROPE, 1991-94 ~ .2Z! ,-~.7 I!.0 o. ,40.0,,~.0 o10.0 .... 18.0 14.4 ...... I1.0 !~' 0,.~ 0.7 '~ ':." ... ~ ~ ..u .'~1 .. ' "-."-' ....'~.~ ,._~' ..... ,~ ....... :,., ~..; ...... ~ ...... .. ,. .~"~..~..~ ................ ~, .... ",~-, .~ .,, ". ..... ;, . ,, ~;,;_.m...;:..~,,:~.~,~.,.~V,..,.~.~ ~ted~,~ .|~ -7n O,O 3.~~ -'~.0olLO -S.O ,4.6' *H.O .t2~l *1~ ., 4.0 3~ ~.0 3n" 93 95 1.7 ..... , . . • . • . ~ ,% ~.:..~.. . . Fluml~/ -I1.~ -4.3 -2.3 o. .19.1 -9.1 4.0 7.I' -5.0 °23.0 ..Sn .. 8.5 12.2 12.1 lI,O' 22~ 21.~ L]~ .!~ 37.7 -|7.0 ,. .I.3 ,S| .6 .4~ .. ~.O -24.(],4.0 .... |.Q |.6 ~2 ~ 0.| 0,|3 . • ~,.~..~ ~.~.~.~._~ ...';~..,-- ~..;~o . ~ . ~ ";,.¢ • .~ .,~ ~.s • ...,..~,a .~ m ',:'~" . ".. ~ ~ -13n -1~ |,0 ,. -1U -21,I 1.3 -|.f -5~ 47.1 1{~ .. 2.9 ~.4 10.2 loci) |JI ~.~ .... . ...... ,. ~:~'~k II~'pu/~c-16A) ~ ,-U) 3,6' -2,5.0 -13.0 -14.0 3,0' -14,0 -12.0 -7.0 ,. 12,.0 I.O I,LO 13,9' IJ $.~ 3.4 U'xrst~ -10~ -17.0 -14.0 ..14.0' -13.0 -15.0 -16.0 °38.0" .4.0 -9.0 .LO o$.0~ o,o 0.0 0.3 0,3~' .. I0 ,.
Page 13: 39000936
Chapter One introduction This report has been written to ~ three objectives: • ,~rsl, to evaluate the influence of env~'onmental pol- lution as a determinant of health in comparison with other determinants of health in Central and Eastern Europe; • second, m summarize current knowledge ~bo~ lo¢.a- riots in Central and Eastern Europe whale envimnmeno tal pollution has influenced human healhh~ and • third, to identify the p~m~ipal typ~ of anvt~onme~- tal expoem'e which are affecting human health and could be aubject to remed~ation tl'u'ough a concerted envi~on. mental action plan. Human health concerns have long ~erved as a principal basis for envi.mnmental standard ~tin8 and intervention among the ¢oun~es of the Organ~tion for Economic Co- operation and Development (OECD). New know|edge o| the toxic effects of even low doses of lead on ddlch~m have led to polities to ~educe and eliminate lead in gasoline. Similarly, evidence that particular chemic~s cause ca~ce~ hae ~esulted in inoea,~ingly sta-ingent controls on thei¢ pro- duc~ion0 use, end disposal. At present, Incz~.singly ~ophisticatect methocis of risk assessment ~ being used by regulatory agendes in the UzdtedStates and elsewhez~ to estimate the rbks to human health o! envlmmnental xonmental policy. ]~u~pe damaging health? If ~, what ~re the key pollutants interventions li.kely to prov/de the largmt ben~t~ ~r the n~soum~ spent? It b not a simple mat~' to anawef th~ question. The populations of Central and F~stem Europe toc~ty te ~ty thn,uSho~t the regior~ In 8ener~ ~ marion about environmental quality lm been ~ame and tt'ucUes o[ the impacts o~ envimm~en~ eXlX~UreS on human health have been inadequate in both number and dedga. F~-~q~ore, there are many othe~ fatten ~ the health of people of Central and Eastern Europe, includ- l~or quality medical care. It is not easy to disentans]e the rbks. ~ wi~e environmen~ ~xmtre is not the only health damage due 1o polluHml is sig~ficant and that act~n What has been the relative contnl~ution of envkonmen- tal po~lution to human health in Central and Eastern Europe? One approach to answering this question is to trace the causes of the w~den~g life expectancy gap between countries of Centra] and Eastern Europe and OECD countries ov~ the past three decades. The ~ expectancy 8ap is a remarkable phenomenon which pro- vldes an opportunity to make krge-scale comp,x~sons of the impact on health ~atus of social condit/ons, env/mn- mental pollul~on, behavlor'a] and I//estyle ~clors, and inadequate medical care. The analysis p~e~ented in Chap- ter 2 shows that the hnpact of envlmnmen~ pollution on health in Central and Eastezn Europe, whUe sig-~icant, has not been as dramatic a.s ~ome popular journalistic de~r/~orm ~uggest. Cl~apter 3 presets evidence regal- In8 the impact on health horn environmental ~ ev/dence shows that morbi~ty due to air pollution in par- tlcular is widespread. Toge~er, C~apters 2 and 3 describe what the health impact of environmental pollution in the ~.,,gion has beam, and what it has not been. The ~ section ~ investment priorities t~ pro- ~ human health in the m~ion. Thee investment pr/od- ties follow from the analysis of this ~eport ~nd/orm the be~k fo~ the majoz ~mmendations contained in the Eun,~ submitted to the minlsterl~ conference in Lucerne, Sw/tzm'knd, on April 28-30,1993. BATCo document for Mayo Clinic 27 March 02
Page 14: 39000936
Chapter Two The Determinants of Health in Central and Eastern Europe The pah'ems of health and dL~ase amon8 popula~ons o~ Central and Eastern Europe differ snarly from those of OECD counn'tes. While there are variations among coun- ~es of Central and Pastern Em-ope, in general li~e expect- ancy for both males and femal~s is much inwer then than in the O~'D countries. This gap Rrst appeared in the 1960s and has be~n widening over the past ~ decades. What are the masons for the w~derfinS I/fe.ex3~ectancy gap between countries of Eastern and Central Europe (Fast) and OECD ¢ounlzies (West)? The~ are many possi- ble ~cplanations. Some have suggasted that low llfe expect~'mcies in the East may be due to hi~,h envlmnmen. tal pollution, di~ctflt socio-pol/tlcal conditions, I~'estyles characterized by d/e~ high in fat and heavy smoking, and poor quatlty medlcaI care. The purpose of this section is to identify the relative contributions o( different (actors to the l~e expectancy sap which emerged be~w~n the West and the Fast betwes~ the 1960~ and the 1980s. l"~e E,~,lution of the Ea~t-We~t Life Ex-pecla~cy Gap The evolu~on of li~ ~cy in the countries of Central and Eastern Europe has pas~-d through two distinct pha..~s since World War ]I. Past came a phase of rapid con- versence with Norih~rn and Western Europe and North America, which h/storically had h~gher life ~xpeclzndes. This phas~ began in the late 1940s throughout Central and Eastern Ettmpe, in the aftermath of World I], and conRn. ued un~ the n~d-1960s. (Its end date, howev~ is some- what indistinct, varying tram the early 1960s in the former Czechoslovakia to the early 197~ in Bu]gafl~.) ~ con- ancy in the Fast conctu'~nt with slowe~ incz~ases in the West. The ~d phase, which has continued to the pms~tt~ has involved • m-em~'gence of the East-Wes~ life expect- has conl:l.nued to rise while fife expectancy in the East I~a stoFl:~f rising, or has even l~m declining. T~ two phas~ are i/lush-ated g~pktcally in Annex 2.1 for males and Annex 2.2 for (~nales. The reasons for the narrowing life expectancy gap are very different ~n~m those characterizing its later m-emer- gence. The rzpld improvements In li/e expectancy in the East that st~rted immediately after World War l! were due primarily to a sharp decline in ir~ant mortality. In the late 1940s and early 1950s, infant mortality rates in the East were markedly higher Chart in the West. But by the 1960s the difference had beep. dramatically cedueed. Annex 3.1 and 3.2 show this convergence between East and West. For /ns~ance in 1952, infant mortality rates In the former Czechoslovakia, the lowest in the ~ast, were 61.6 and 40.9 per 1,000 live births for males and (emales, respectively. By comparison, infant mortality rates in Sweden in 1950 were 24.3 for males and 18.5 for females. By the early 19~Os, tl~ gap of 37.3 deat~ per 1,000 live bh"ths in male infant mor- t~li~y had narrowed to less than 8.7, while for females the gap had shrunk from 30.4 deaths per Io000 Live births 6.9. In Poland and Hungary, ir~ant mortality rates contin- ued to converge rapidly to Western levels until the mid- 1970s. ThereaRer, wl'd.le irdant mortality continued to decline in most countries of Central and Eastern Em~pe, there was not enough uncontrolled mortality left in infancy to influen~ l~e expectancy t'mnds very much. The reasons for the n.*-,.-mergence o~ the Rf~ expectancy gap be'c~een ,~,ast and West appear to be due mainly to ~erences in health status after m/ddle age in the two mSions. In general, life expectandes for those older than age ~ have not/reproved much, if at all, in the cot~ntries Eastern and Central Eur~Fe. This is espedally i~ue for males. In the West, life expectandes for males have improved dur~g the last three decades, wl~e in the East, li~ ~ancie,J have been stas-nant or l~ave even declined. Li~e expectancies for ~emales over ag~ 30 have imp~ved in th~ East during the post-war Period, but not by as much ~s in the West. The followin8 tabl~ illustrates th~.se patt~z-ns aggregated over seven countries. In summary, the evolution of li~ expectancy in the East has undergone two phases. Dudn$ the first, lasting the late-1940s until the mid-196Os, rapidly declining infant mortality rates led to a near converg~xce o( East-West [~e expectancy. During the second phase, lasting f'mm the BATCo document for Mayo Clinic 27 March 02
Page 15: 39000936
CSFR 39.1 39.S -0.2 Poland 35.9 39.4 0.5 Hungary 39.6 38.2 -1.4 Canada 4h6 44.9 3.3 US ~.O.0 ~33 3.7 Sweden 43.0 45.6 2.6 Japan 36.7 46.9 10.2 43.0 4~.2 3.2 43.0 46.9 3.9 ~ 4~.5 2.8 44.9 Sl.O 6.1 ~4.9 49.7 ,L~ 44.6 St.l 6.~ 40.0 52.3 12.3 m~d.1960s to the present, East-We~t di~erenti,~s ~val ~erg~, due p~y to ~ ~val s~ ~ ~ddle age. A New ApFma~ to ~yz~8 ~e ~e ~ Gap ~e ~'oluflon o~ ~e e~n~ ~nds to t~ ~ond the usual ~la~fio~ ~r d~emn~ab ~ ~e e~n~ Japan now ~ ~e ~gh~t ~e ~n~ ~ the world, ~ ~h I~ ~ant mo~l- i~. m~ and ~gh supp]em~m~ ~e ex~n~ for ~I~ and le~l~ ~m early ~ddle age onw~. ~er- mo~, Japan ~gan the ~st-war ex~ndes than the ~st. ~y ~s Ja~n ~ ~ ~c- ~s~ ~ ~pro~ ]~e ~nd~ w~e o~ co~ ~ ~th s~ar ~r ~pita ~m~ ~ve no~? ~ the past, a~lysts tend~ to assume ~t ~yond a ~ level of ~r capita ~come, the~ we~ few addS- fio~l health gains ~q~h ~g p~d~ He~ we l~k ~yond pu~ ~onomic fa~o~ to ~ ~e~- ~o~I diHe~n~a~ ~ ~fe ~n~ to ~no~c condition, ~cIud~g such ph~om~ as ~ mor~ We ~s~e t~t ~he ~cono~c ~ndi~o~ of a ~n di~/y ~uence the health ~s app~ch ~ ba~d on an a~lo~ ~ ~e e~- an~ ~adients by ~ono~c ~ss ~, and ~e ex~an~ d~e~n¢~ ~n w~ch d~er ~ the~ level of ~ono~c d~elo~ent. ~n~t~l a~ ~ccounting Frank A ~d ~mework ~ n~ to eval~te ~e ~oludon of • e ~e~ork shoed a~ow ~ to ~id~ a ~ ~e of ~ssible d~n~ of h~lth. ~e foBo~g d~ion p~nts such an app~, w~ ~ ~ ~ a ~n~ ~I ~d as an ~I~I a~g ~ework for ~e d~e~ of h~Ith a~ ~o~. 2.l), ~ the t~ ~m ~n~ ~e ~ ~ ~e~ sio~ ~or a~lys~. ~ ~ ~I~ as smg~ ~ ~e ~e ~cle, ~p~Hon pa~o~, a~ ~ of h~en~. ~ ~ ~ntext, h~e~ mea~ v~/d~ ~¢~/~ua~ ~ health s~. ~e ~ d~lo~ s~a~s be'~veen de~ned popu~tions, and do not con~itute • ge~er~ model of health and disease. STAGES OFTH~ LI~ CYCLE. The l~e cyde ~ ~- to ~e study of h~en~ ~ h~ s~ ~ ~ ~e ~s~ o~ biolo~ ~ge ~ ~ ~di~d~ o~- ~. He~ we id~ fo~ s~g~ ~ ~e ~e d~ w~ ~e~t ~ of d~ or ~ndifi~ ~ p~ do~nt. ~e ~I ~ ~ a ~i~ion of ~e ~e ~e ~t ~ ~ ~nt ~t i~ s~ ~ve ofl~ ~n ~ ~ ~r health ~i~to~ for ~p~Ho~ (e.~ ~ m~l mo~ m~ ~d b~ weight ~m~u~). ~e ~H~ ol "~dven~" ~ds ~m I~ ~ one y~r • e age at w~ ~c ~a~ of ~d~e ~e ~ to ~ve silent ~ ~ ~ W~t, ~ ~t ~y ~ ~ • e ~d~s, but ~ the ~st ~y ~ ~ the ~t~. ~g ~ bu~ ~th~ a~d~ts, Holence, ~d s~ffde. ~ ~n- ~al t~, ~e ~st-W~t ~e ~ gap ~n~t ~ ~p~ by h~Ith outcom~ ~ ~ ~. ~e ~ ~m ag~ 4~ to 74 y~ ~y ~ ~ ~e ~ ~e ~pal d~a~ w~ch ~ten h~ ~d ~e. ~e te~ "d~enera~ve" b ~ h~ n~ ~ ~di~te p~ ~o~ d~d~ of"w~r and tea~ (as web as a ~ di~, ~ of exe~, smo~ ~c.) ~ ~t ~ ~u- ~ter y~ of ~ age ~nge ~t one ~y ~0y t~ a~l~ ~ ~to~ ~ ~& ~. It ~ ~e ~[- ~t, mm~ ~ ~e Wmt, w~& ~~ ~e ~t- W~t ~e ~ gap. ~e ege of 75 ~ a~i~a~y id~ ~ ~e o~ of ~e heal~ s~ ~ o~en d~e~ by ~e bte ~d mua~y I~ ~c ~ of c~c de~ne~ve d~ t~ d~n~on. ~n~l s~v~ ~ ~ ~ ~ n~ a p~pal ~n~butor ~ ~e ~t-W~t ~e ~- ~ gap. ~e ~e ~e app~ ~ a~on on ~I BATCo document for Mayo Clinic 27 March 02
Page 16: 39000936
Sources of Heterogeneity Alternative Paxtifionl ~ Population aracte~s~c ,,, Status Of the Life Cycle Stases of the Life Cycle L Pe~inat~ pre-te~m to ! yem- 2. Mi~dvent~: 1-44years 3. Chronic disease: 45.-74 years 4. Senescence: 7~÷ years Population Partltton~ I. 2. premature chrordc degenerative disease. But this is not necessarily the I~ne at which the principal de~trminants of differential mortality be~in to have their bioingica] effe~. Since the framework attempts to account for between-pop ulation differences ~n health status R must, by definition, begin by reco~.ing the expression of health status and then work ba c.kwa,-ds in lime to explore its determinants. Sotmcr~s OF l.~'T~ocmq'Er~. Thare a~ many types ~ c~usal p~thw~ys or mech.~dsms which might l'd to the d~- ~enom ~n heslth ~tatus which a~ observed aacss ~ t~on l:zrtitions and stages of the ~ cy~ Each I~s radically d/~f~nmt ImpI~c~ions for how we think about the orlgim of health and dL~ease, and about polldes to address them. cussfon oRen focuses on the foPJowing six mechardsms: a) P/q/sic~l env/mnment. Di/ferent~ exposures to phys- icaJ, chemical, and biological agen~ at home, at work, and in the conununity ~s~ differences in health stat~. b) Differential acc~s to or rnpor~se tO health cart Differences in health status may be related to differ* ences In ca.re seeking behavior, the quality of health services and access to them, or to d~erenttal oul- comes for a ~iven treatn~ent. c) Individual lifestyle. Health habits and behavior-, of those in cLtffere~t sub-gmup~ result in d~erent risks of partic¢lar life-~te~g or disabling cv~ditior~. d) 54x'ial and e~onomk environnu, nt. DiHerences in sepal and economic cond|tion.~ in width people live result in dlfferent~.l health outcomes. Important c~ndi- t~on~ which may ~ health include ,u~I isola. I~on, deprivation, stress, and a sense of conUvl. The rival two soth-ces of hetervgeneity have to do with the way we conceptualize the problem. e) Rever~ causality. The actual causal pathway is posed in reverse of what is L~tial~y supposed. For example, if the prevalence of peno~ with mental health pmblema were higher in the city than the sub- urb~, the reverse causality approach would ask "to what e~tent de p¢~o~ with men~ heath p~blems BATCo document for Mayo Clinic 27 March 02
Page 17: 39000936
m/g~ate to the cities, rathe~ than the ci~les being a ~u~e o~ ~t to one's men~l health?" ~on ~nt ~e~ ~ ~t~ ~tential or else ~nles In the lev~ of ~e t~c are de~n~, ~ p~, on ~iol~! ~/an~, the a~ment ~y ~ ~de ~t ~l mobi~ ~ i~ ~ on ~tly hvo~ble c~ra~e~ of the ~dl~dual (e.g. as ~ ~ of genetic or early c~dh~ ~) w~ d~e~e ~er p~ ~r he~ s~. CompeHng ~l~tions for ~e C~enl L~e ~e~ Gap ~e s~ ~ of hetemgen~ id~ a~ve mfl~ ~ 6ve app~ches to ~e ~s~-W~t ~e ~ gap. ~ ~ve appr~ch~ am d~ m~d~ of t~ chapter. ~ ~t~ long and di~i~l su~ibili~ ~ ~ ~e da~ ~m "~el~ropa" ~c~ng back ~to the 19th C~- ~ which show tha~ ~s~-W~ d~e~n~ ~n ~e ~ We ~n the no~ owr ~e past h~d~ ~th ~e~ of ~ ex~n~ ~ ~e ~st ~g~g • e ~ by a gene~fion or ~. ~ [~s comex[ the p~ of ~nve~ce ~ I~e ex~an~ a~er WoHd ~ar ~ ap~a~ to ~ an ano~Iy w~ch ~n easily ~ ~pia~ as In the ~t-war ~, the ~s~ ~x~fienc~ a d~e ~ant mo~[[~ s~r [o the on~ that ~d ~ Bet ~ the W~t. However, du~ t~ ~H~, ~ ~t d~eases and therdo~ was not ma~ng silent gal~ ~e ex~an~. ~us, the ~ of convergence was a tofical a~a~, and the long-~n ~nd was ~to~ when the W~I eme~ a ~ ol ~nement o~ mo~ ~m c~o~c di~ase and the ~st, in,Habit, s~ to ex~ence ~ased mo~ali~ ~m c~c ~. ~ the ~me, t~s app~ch leads to ~o ~mely, t~t c~onic d~ease mo~ ~ ~bly ~ to d~e ~ the ~sl, and, p~bly, ~t ~I m~s~ n~ to ~ ~ken ~o asset ~e A~ ~I g~nce, ~he ~tofi~l long wave ap~a~ d~fi~It to ~te. By de.finn, it ~ ~d~ ~ the ~p~l eHd~ce of ~st-W~t ex~n~ pa~e~, and it ~ eas~y ~ ~ by ~b~ ~ the p~p~on ~t ~e ~sUs ~t ~ o~ s~on or d~e ~ ~-~d~e a~ ~ppl~ men~ ~e e~n~ must i~bly ~ foHow~ ~s tu ~ ~ble, the ~ants w~ mo~ wo~d ~ve to ~ mo~ ~e t~n the ~ who w~d We s~v~ an~ay. ~ ~a~e ~ w~d We to ~ch ~ddle aga and ~ to ~e of ~c (primarily ci~'uIatory diseases) at hi~er rates than their hardie~ siblings. In other words, the increase in chronic disease mortality would have to follow the decline in irffant mort~ty rates by at least ~ years. In the case of the East, infant mor~aU.~ declined most dran~c~lly in the |g.50~, but ineraases in chronic disease morta[/ty were notable beginning i~ the 19C~s. "['be ti.ming is wrong for the frlgiI~ty hyp<~hesis, or, at least, a parsi~onlo~s ren- dering of it. In addition, the Japanese experience does not suppor~ the l~storlcal long wave approach. Du.,'ing the post-war period, Japan, ILke the East, experienced a rapid decline in infant morta.liW. But it w,s not accompanied, or followed, by hobble increases in ch~nic d/sease mortal/ty In fact, Japan experienced rapid ga/ns in supplementary life expecta.~-y after age 30 during and after the period when Infant morta//ty was decUn/ng. It m~ght be argued that compa.rL~oP, s with Japan are un~ah" Kmce immediately after the war, Japan was merely ~covering • level of public health that had been ach/eved before the w~r ~nd lost du.ough devastation. $6/I, the Japanese experience shows that there is no inevitable historical sequence of declining in~ant morta]/ty and stagnating or decl/ning supplemen- tary Rfe expectancy ~m middle age onwards. Historical comparisons of the evolution of l~fe expect- i, ncy between the Baltic countries and F/nland also pro- vide important evidence to rebate the l~storical long wave approach. The Finnish experience/s vi~l because it was part of the Czar~t empire untl] 1917, and, I/ke the Baltics, experienced a pericx/of independence between the wars. However, relieving World War 11, Fin~nd remained inde- pendent wh~e the B.dtics were ~eincor/~rated into the Sovle~ Un/on. Tlds makes ~he h~storic~l comparison of the evolution of ]~e expectancy a kind of ~uasi-experiment, with all variables held constant except the narm'e of the post-war pol~tical and e~onomic system. Table 2,2 contain.s data for F/niand and Lat'v/a. These two coun~'les emerged ~-om mo~e than a century of C.~ar- ist domination with virtually identical l~fe exp,'fancies. This dm~arity remained unchanged b~oughout the inlet- war ~riod and afterward unti/the late 1960s! During the 1970s and earl), 1980s, a We expectancy gap emerged: 6 years for wales and 4 year~ for females. This is the best evidence we have so far that the I/re ex~ncy gap can- not be at~buted to a historical lag of East beh~d West, or to changes which were evident Immediately following the establishment of the 5oviet Union. The gap must be ~ly meted in East-West d/~e~.nces in the conditions of l~e dm'ing the 1960s, 1970s, and 1980s. Th~ approach attempts to determ/ne the extent to which diF~,re~t~l exposures to e~vironmental poUut~on are responsible for the East.West li~e expec~ncy gap. The expeC~nc7 gap stoned to widen dm'ing the ~ne Ix'rind t~t the co~nl~ies in the West started to -ddress the prob- lems of air, water, ~oi], and ~ pollution. Wl~le of E~tern ~ Central Eucope had ~dopted env/mnmen- ~I pol/des simll~ to those in the West, these were not gan- BATCo document for Mayo Clinic 27 March 02
Page 18: 39000936
• rally e~t~l. Exposure to ~h levels of pollu~a ~ su~ ~ ~to~ ~, ~ ~n~, ~d ~ ~ov~r d~, and ~ l~d ~ ~nge~ uI ~d developmen~ ~bno~ Mo~ ~ a ~ut~ ~ent ~ ~ v~ d~ ~ ~ple's Under s~ condifio~ ~p]e ~y ~ ~ ~Jve ~aten the~ h~ ov~ ~e long t~ s~ ~ ~e~ ~ su~ ~dence suing ~t ~u~on oEthe physi~ en~ent ~ ~ h~l~ ~ Cen~ ~d ~st~ E~ ~ ~ou~ ~ ~d~ d~ not add up ~ a con~ ~ that the d~on water, ~i], and ~ ~ the ~I ~ of the ~e ex~n~ gap. ~di~ of s~-[~, ~wiy de~, g~p~y l~, and non-~te~ ~g heal~ p~ble~ off~ ~dence of heal~ eff~ due to i~ ~ the ~t. In con~t, ~ a~ ~w ~n~g ~fion ~ the ~st ~ w~ to ~te ~bn~ble to ~en~ ex~. S~ mo~ ~ p~y due to ex~u~ over ~on~ o~ ~e, su~ smdi~ shoed ~ ba~ on ~e meth~s of c~c d~a~ epide~o]o~ ~ wou]d ~ 0) ~ong-te~ s~di~ of ~eg~ ~u~ ex~ to ~uUon compa~ ~ ~ not ~, or (fi) account of ex~s~ to va~o~ ~u~n~ we~ ~en ~. ~ cou~ th~ s~dl~ wo~d ~ve ~ ~ke ac~t of health ~ ~m ~le end ~ono~c ~ em Eum~. ~ost o~ the s~di~ ~ d~te ~ve [~k~ ~a~o~ps ~n en~ ex~ ~nd mar- ~fi~ by eider 8~p~c a~ or ov~ ~e, ~thout ~n- ~l~g s~ently f~ com~ ~ of ~k er ~e paffe~ o~ ~dJ~d~l ~s~ over ~ peJ en~en~I p~lem ~Hy ~b~ of ~u- ~I and ~stem E~, ~ ambi~l con~a~ pa~te ~ff~ ~d s~ dio~de ~ ~e m o~ ~nd and ~ny ~ple. ~ ~u~on ~ wont ~ wbe~ ~ ~ ~ far hea~ ho~ ~d ~rly ~to~ce ~w), S~di~ ~ ~t ~ su~ fio~ should help ~ d~e wh~ or n~ ~ fion b ~S ~Uo~ ~ds ~ ~e ~n~ ~ ~ ~ ~ exte~ive ~te~ ~ ~e dlo~de ~ leve~ oi ~c~ mo~ It b ~le ~bient a~ qus~ da~ and n~ ml~S un ~ avtiLtble data on human health which mppod the hypothesis that environmental pollution is contn'butlng to exce~ mortaJ/ty in $iJesia and northern Boherrda. These obeervations are not confined to a/r pollut/on. S/I.E.. In 1983, the Polish Cotmcll of MinSters offi- cially designated 27 areas in Poland as "areas of ecological ],~_zard/' based on measurements of air, water, and soil ]~ollu~on. These comprised II percent of the co~try's ter- ritory and ~ pe~ent of its popu~a~on. The five worst were ident~ed as "areas of ecolofi/cal disaster," Since these ~ correspond ~sanably well to the l~undaries of Poland's 49 provinces (voivodships), and certain health data are reported by province, it is possible to evaluate whether or not some indicators of helath are negatively as,u:x~ted with the areas of ecological disaster. For m~les, 7 provinces in Poland were among the ~/gh- eat I0 in ali.<anse mortality for each of two years for which data were available (1987 and 1988). The list of 7 i~cludes 2 areas of "ecolob4cal disaster': Ka~ov,dce and Elblag, (the ~ter fall~ wit.~Ln the Gdansk area of "eco|o~i- col dL~ter"), Four are regions of "ecolob,/ca[ h~zard." For females, 5 provinces were sire/lady among the highest I0 for mortality in both 1987 and 1988. These included the l~to'~ce area of "ecolog/cal disaster," and 3 areas of "eco- lo~ral l~.ard." '¢~en one is concerned with general envi- ronmental in.quences on health status rather than occupa- l~onal influences, finding sim~ar patterns for males and females is of great importance. Thus, Katowice stands out as an area of where environmental condlt~ons co~d be affecting health, because both male and female mortality rates are high there and because it is classified as an area of "ecological disaster." Within Poland, there are large differences in ir~ant mortality rates by province. For L~tance, in 1987 there was a 75 percent difference between the lowest and high- est provincial infant mortality rates. Three provinces had Ir~ant mortality rates consistently among the I0 highest in the country for three consec~Hve years (1986-88). Katow- ice was one of the~e provinces. Because of its industrial- ization, l~,atowice is relatively prosperous by Polish stan- dards and so it would be difficult to explain this pattern on the basis of sc~o-e,:onomic factors. Furthermore, one study done within the Katowice region found that infant mortality was associated with ambient air quality over a six-year period during the 198C~. The strongest associa- tion was with dust fall, which accounted for 14.percent of the variation in Ir~ant mortality. Th~ likely underesti- mates the explanatory power which might have been found w~th a dust measure more relevant to human re~pio ratoW exposure, such as PMlo (particle~ ec]ual to or below I0 microns in diameter.). Another ~reature of mortality in Poland which suggest~ an envircmmental e~ology is the relationship between urban and ntral mortality. In the We~to ~ban li~e expect- andes are consistently higher than rural ones. This is thought to be due to the socioeconomic advantages of urban living in the West which more than offsets the dan- sers due to poliutlon, violence, and motor vehicle injuries. However, in Poland, a&e standardized mortality rates are BATCo document for Mayo Clinic 27 March 02
Page 19: 39000936
1921-30 507 50.7 55.1 56.9 1931-40 54.5 5~.4 $9.6 60.9 195~-~ 64.9 65.2 7].6 72.4 1~71-7~ 66.7 65.2 ~3.2 74.4 '1981-83 70.'1 6L'1 ~8.4 74.4 1988 70.7 ~56.3 ?&7 73.1 The m/ning dbMc~ of northern Bohem/a aho have hi~er age-stancla.-dized f~r I~ ~Io~ ~d sto~ • e u~ ~r ~) Howev~, one ~t ~ ~u~o~ ~ ~ ~n~- m~om for ~e ~. ~e ~ as w~. For ~ple, ~e mu~ ~gh~ ~vo~ .t~ ~d a ~h~ ~ of d~ not d~r ~k~ly ~n ~e ~. ~o~p~c va~bl~ m o~ ~t~ ~ h~l~ s~. ~e~o~, It h ~t ~ ~d~ • e d~ to w~ ~I ~dv~ge, ~8o~ ~d d~on ~8ht ~n~ wo~d h~p ~e~ to Table 2.3 Evolution of Life expec't~qcy In the C..~.h and Slovak Republics by province Northern ~ohemJa 66.2 64.6 66.1 72.2 71.9 73.8 Western ~he~a Middle ~he~e 67A ~.9 67A ~em ~he~a 67~ ~.5 ~ ~ ~.8 74.9 ~J~e 67.7 ~.4 ~,7 ~ ~8 74.9 Northern Morsvi= 67.3 M~2 68.4 ~'3.5 73.2 74.4 Southe~ Mora'v/s 69.0 67.2 68.4 74.4 74.2 ~J.7 Middle SIovtide 458.0 66.8 67,0 ~;2.4 73.2 75.3 l~ttern Slovaida 68.4 66.3 ~6.6 72.6 72.9 74.9 Western S]ovakla 6~.7 66.8 ~.9 73.1 :73.1 74.6 6raUslava .. 67.7 69.4 .. 73.2 73.5 BATCo document for Mayo Clinic 27 March 02
Page 20: 39000936
Table 2.1 Relative risl~ of neonatal ln~blema In dtatrI~.- e~ ~he Czech Republic ~ by air ImlIulion /nf-~nl mortality tam 1.0 Polme~rml~ mon:allty rs~ 1.0 Poa~t~ratal r~ptratm-/morality mt~ 1.0 ~ blzth wet~,ht 1.0 1.11 l.lJ t.7~z 1.-~ 1.24 1~37t 1.24 1.51l 1,02 1.02 1.02 ~:~, &plxk,+ 0,01 ~, ~h ~) I~1 One well-desired multivariate study looked at infant mortality in relation to ambient air pollution from 1986- ~ in 42 distrl~s o~ the Czech Republic. The study included so¢io-demograpkic variables obtained vital stat'ist/cs and from a survey done by the Federal Bureau of 5~atist~c~/n 1978. The researchen divided the dlst~cts into quintiles a¢cordlng to the sum of the annual geometric means of sulfur d/oxide and suspended dust. Table 2.4 pr~ents the re/afire risks for infant mortality, postoeonatal mortality, postneonatal respiratory mortal- ity, and low birth weight by concen~'alion quintile. The relative risk is arbitrarily set at 1.0 for the lowest cancan- tx'a~ion quintile, so values greater than 1.0 indicate Incceased risk of mortality (or low birth weight) for other exposure quintiles. Each analysis ts adjusted for mean income, mean savings, mean ~ar ownership, proport/on of iIleg/timate births, and abortion rate. These data support the hypothesis that air polluUon is con~but~ng to hig~ ir~ant morta~, especially mortality h~m respiratory causes. GENE~,AL A~P~O^~. A more general approach to measuring the health impacts ~roua ex]~mlre to pollution comes f~om an emerging literature wh/ch defines dose- resporme relationsl~ps between exposm'e to dust and sul- fur dioxide on the one band, and mortal/ty on the other. The studies for particulate n~tter, which ~ve been car- tied out for a variety of local~ous and cl/m~tes in Europe and North America, have pr~luced very consistent results. The~ suggest that a 10 microgram per ruble meter (~glms) increase in mmual average cconcentrations of respixable dust may increase mortal~ty by between 0.3 and 1.5 percent' with a mean of I pm~e~t Studies for sulfur dioxide, wi~le ~omewhat less consistent, also show a rela- tionship between c~ncen~rstions Of sulfur dioxide and mortailty. These suggest a I0 pglm~ Inere~e in armual average sulhaa" dio~de concentration~ may increase tallty by between 0.2 and 1.2 l~.re~at, w~th a mean o£ 0.~ Conceptually, the con~bution of these air pollutants to the East-We'~t ~e expectsncy g~ap could be based on estimates of the relative increase in the gap between average ambient concanWa~ons ol PM~0 or suLCm" dlox- ida in Central and ~astern Eusope compared to the West over time, multiplied by a best estimate of the response to this "dose." For example, consider the data presanted in Table 2.5. These da~ show that, over the 15.year period the average sulfi.u" dioxide level in OECD dties declined by 114 micrognu~.s ~ cubic meter while incre,~in$ by 69 microgran'm ~ cubic met~ in the regions of northern Bohemia. Thus, by 19~5, the annuaJ average concentra~iom of sulh.tr dioxide was 183 n~c:~-rams per cubic meter higher in regions of northern Bohemia (i.e. 69 - [-114]) compm'ed with OECD cities with a range of impact on moz~ality of between 4 and ~ peseta. We ~ lad~.~g IKstorical I=end data for l~rti,.'ulate mat- ter |~r Central and Eastern E~trope which would enable us to make a similar ~alculation fi~r dust. Instead we have made t'~o cro~,s-sectional comparisons using data/ram the 1980s. In the first, we compared the m~ximum and minimum annual average dust levels from 7 dries in northern Bohemia and 13 OECD cities for the yea~ 1981- 88.t We then ~leulated the dl/~erences in minimum and maximum mmual averege PMm levels to represent the plausible nmge of dLqerences that might exist between ~orthern Bohemia and major populati~ centers in the OECD. The range was 31 to 62 micrograw.s per csabie meter. Applyin~ the minimum esl£mate of mortality Impact (0.3) to the rain/mum estimated di~eren~e and the Table ~.S I-Ii~torlc daangea in average annual sul/ur dlwdde coneentntion~ I970 I97~ 19M 19~5 OECD dHe~ 1511 7~ ~ 3~ CI,,~mut~v region 53 ~t 94 l~ 0 O0 co BATCo document for Mayo Clinic 27 March 02
Page 21: 39000936
max~um mortality es~te (1.5) to ~e~ ~, m~vely, 1 to 9 ~t of ~ m~ a~bu~ble to ~gher l~e~ of PMm ~ no~ ~h~ ~n ~ OECD averase •mblent co~cen~o~ of P~10 ~ 11 i~ ~ concen~o~ ~ II OECD ~fl~ ~r 1987, a y~ ~r w~ch ~b~e dz~ a~ ~v~ble for S~, for S~ was 1~ ~ ~ ~bic m~ s~nds to ~ ~ge ot ~ mo~ of ~ ~L ~ly~ w~ch ~t ~th the~ v~di~ and ~ of ~ter- p~on. ~me ~t~ of ~e ~m~ to~ t~t ~ght exp~ exc~s mo~, su~ ~ n~r- ~ the average davy ~bient ~n~n~on of ~e ~ut- ~t of ~t~t. It b a ~e me~olo~ ~p to appJy ~~ ~o~ ~m su~ ~di~ to f~nces ~ av~ge a~ual con~n~a~o~ ~ ~te ~o~ of the world, as ~ ~n done h~. ~e ~sib~ of a ~hold ~ow w~ ~ ~ a~t~ ~ a~ ~u~on ~ not ~ ~u~on and h~Ith we~ ~low ~t ~t~o~ da~s, at le~t for PM~0 (~ ~, ~.~, I~3). ~ ~ddi~on, ambient da~ ~m ~st ~d W~t ~y not ~ comparable. ~e~ a~ ~eral ~ccept~ m~ for ~g. m~su~& and a~ly~g da~, ~d ~t ~olve and ~p~ve over ~e, ~ daU ~m ~t ~y ~ for p~te ~, for w~ at ~ alte~ve m~s~ a~ ~ ~. For ~ ~I~ we to ~ two convmion fa~o~: one to ~e s~d~ E~ ~an and Noah ~e~n m~s~en~ ofd~ ~y ~uival~t ~d ~oth~ to ~ke ~ of ~ ~y ~v~ent to PM~0. ~ of ~ ~nvmio~ ~t. ~ it ~ ~ ~ how ~ ~ ~ ~u~n Despite these problems, there is sufficient evidence to suggest that alr pol~ution has affected moaality in the moet heavl]y polluted part~ of C.entra] and Eastern Europe. However it is dI~cult to precisely measure the m~imde of this e~ect. If Silesia and northern Bohemb help to put a concep- tual upp~ bound on the contribution of air pollution to the I/,~ ¢x'pec~'~cy ~p, the,-t c--,-,-,-,-,-,-,-,-~m~-y-to<ount~y varia. tiom in iffe expectancy within Central and Eastern Europe help to establish the lower bound. It turn~ out that the same basic pattern of evolution in He expectancy ex:~ts in ill of the co~ntr/es of Central and Eastern Europe despite the ~act that pollution conditions in these counties are m~rkedly different from one another. For ir~tance, the Bal- tic ¢mmtri~ do not have any ~'ess which compare to $ile- si~ or northern l~hem~a and yet llfe expectancies an~ no higher than in the Czech Republic or Poland. Thus, when the mortality impacts in the most polluted parts of the countries of Central and Eastern Europe are averaged out a~ the whole pofmlation's li~e expectancy, they become diffic~It to detect. Ha~/th ¢ar~ end t/~ According to this approach, contrally.pla~med ~cieties were well suited to provide public health sc~'ices to the masses, but unable to adapt to high-tech modem medi- cine. Just as the econom.ios of the ,Vast seemed unable to m~ge the transition from industrial to service and infor- mation ~x:~e~es, they could not me~t the ne~-d for incn~sed local autonomy, professional ind~>endence, and strategic capital formation that some observers believe is fundamental to a succe~ful health ca~ system. Further- mor~, throe problems were exacerbated by • shortage of hard cun'ency in the East, in~easingly needed to pmcha.¢e Western equipment that was not available from Cenh'al and Eastern European producers. Thus, despite i~ ~upply of health professionals, the East was intm-.asgngly unable to match Western stand•his of diagnosis and t~at- ment of the chronic cE.seases that m the principal causes of mortality. The valld/ty of this approach depends, in principle, upon whether or not the case-eatal/ty rates for the~e principal iffe-threatening conditions differ siguifi- cantly bet~vesn East and West. "[he~ I~ co~tderab|e dive~,ence of opinion about the extent to which medical care has contributed to improving the health status of polmlations over time. For instance, it is widely believed that vaccination and the use of antibiot- ics m'e mponsible ~r the near elimination of mortality fn~n ~o~s diseases in the West. Yet, massive declines culo~is, smallpox, and measles occurred several decades to two centuries befo~ the introduction of effective vacci- nations, This observation, which is most closely a.c~x:tat ed with the work of Thoma.~ M~ ~ led to debate about the relative importance of nutrition, housing, public aspects o~ econom/c ~nd ggisl development. Some .... LIIIIII _lill LJ l~- ~i__I 9 ~ BATCo document for Mayo Clinic 27 March 02
Page 22: 39000936
have contributed slgr~ntiy to improvements in health. It is likely tha~ hUnCh ll/e expectancy lncre~,d ~rom approximately 40 years to (:0 years without significant assistance f'mm effective, individual-based txeatment of society's most ~e-threatening and prevalent dLseases. Does the same situation prevail today? Is medical in this l~-iod oI cl~onic disc•sin making as small a contri- bution to reductions in mortality es it did i.n the era of infectious di_~ases? Although we lmaw that many curt'era methods of clinical prevention a~d treatment of d~ are efective, we do not have convincing evidence that medical care Ls contributing more to health status now than in the past. More to the point, however, Is whether or not health sen, ices in the East are less elective (or more dangerous) than in the West--enough to co~m'Imte ~abstantialIy to the East-West l~e expectancy gap. Many indicators of the qual~ty of health ca~e am similar in East and West. For example, the numbers of physicians, nurses, and pharmacisis per capita are about the same in both region. In addition, people in both ~8ions utilize health services at about the same rate. In Eastern and Cen- tral Europe. hospital beds, admission rates, avenge lengths of stay, patient days, and physician visit~ per cap- ita e.~ all currently within the range of OECD countries. And while health expenditures as a h'acllon of total output are generally lower in the East than the West, this is not likely to explain differences in lLfe expectancy between the two l~or~. As an example, in 1987, the former Czechoslovakia spent about 5.8 percent of ils Domestic Product on health care, not slgni~cantiy di.ffer- ent from Britain and Denmark, both of which spent about 6 pe~:ent of GDP on health care. lap•n, with the longest ll~e expec~ncy iq the world, spent only 6.8 percent of Its GDP on health care in ] 987, while the United States, which has comp~a~ively high infant mortality and low ILfe expectancy, spent 11.2 ~ercent of GDP on health c~re. Moreover, a~ong co,.rattles of the E~'opean Union, the nation~l level of heaJth care expenditure does not even correlate with mortality rates for "medically avoidable causes of death," a composite indicator ol cause~ of death which ought to be avoidable through prompt and appr~- prlate medical attention in the acute phase of the disease or through effective secondary prevention. One study compared mor~Ety In ~lected Western countrles and the former Czechoslovak/a, Hungary, and Poland ugmg • slm- tlar index of "conditions amenable to medical care." The index includes 22 condi~ons or famll/es of related t~on~ among indiv/duah 0-64 yeare old. A/though the study was not mean~ to highlight changes in the rdat~ rate of mortality ~om medically avoidable causes between East and West, it is po~lble to partially recore Table 2.6 Me~cally avoidable death rates sl~'uct this ~ the data presented. Table 2.6 presents data on mortality rates standardized pe~ 100,000 European standard population for the former Czechoslovakia and England and Wales. The table shows that wh/le deaths from medicaJly avoidable causes increased In the former Czechoslovakia relative to England and Wales between the t~o t~me perio ods, de~b~ from non-avoidable c~,~es increased even more. Th~s only ab<mt 9 percent of the total (relative) increase in mortality rates in the former Czechoslovakia compared to England and ],Vales can be attributed to med- ically avoidable causes.2 Similarly, about 12 percent of Hungary's and 15 percent of Poland's mortality differen- ~ with England a~d Wales can be aRributed to medi- cally • voidable causes. T~e con~b~tion of in~iv~u~Z li~.style factors ~ approach begins with the observation that, for both sexes, most of the age standardi2ed mortality differential between East and West ,~n be attributed to a single cause: higher ch-culatory disease mortality rates in the East, which emerged concurrently with the [i/e expectancy gap. Therefore, East-West differences in smoking habits, blood pressure control, and diet or cholesterol levels--the epide- minlogtcally validated risk factors for heart disease and stroke--can explain the li/e expectancy difference. The public policy corollary of this approach is that wen- designed health promotion programs will be the most effective way of eliminating the ~e expectancy gap. The ri~k factor approach starts by ldenti/ying the dis- eases that appear responsible for the East-West mortality diferentia[, then attempts to identify at~d analyze the risk factor~ for the diseases. The evidence indicates that cardiovascular mortality (sometimes referred to aa circu- latory disease mortality) is the principal cause of East- West mortality differentials for both males and females. Table 2.6 shows that in the West, cardiovascular disease mortality rates declined sharply for people of both sexes • god 45 to 74 years from 1960 to 1979. By contrast, mor- tallty rates/or this cause increased sharply in the East for males aged 45 to 64 over this same period, and for males aged 65 to74 from 1960 to ]976. For example, the rate for males aged 65 to 74 in Czechoslovakia increased from 2,22S per 100,0~XI in 1960 to 2,772 per 100,000 in 1976. These increa~s were followed by only small increases (in Czechoslovakia and Poland) or even declines (in Hungary) in the late 1970s and 1980s. For fern. ales aged 45 to 74 in the East, can:Uovascular mortality rates have in general fallen between ~960 and 1989, but at a m~ch slower rate than in the West. Therefore,/or both males and females, the gap between East and West in cardio- CSFR I01.0 3.~.I 72..~ England & W~les 69.6 298.2 35.0 252.0 10 BATCo document for Mayo Clinic 27 March 02
Page 23: 39000936
vascular disease mortality rates has widened g.r~atly ove~ the last ~ decades. What Is the cause of the increasing differ~n~l/n East- Wes! cardiovascular mortality rates? The gap has been increasing during a time when per capita cigarelte con- sumption by men, and to a lesser extent among women, was increasing in the East: cigarette sales per capita increased by approximalely 30 percent between 196~ and 1985. There is also evidence that people in Hungary have been consuming more fat, especially animal fa~s, over the past several decades. Between 1934 and 1988, annual per capita consumption of fats increased by approximately percent in Hungary, wi~e consumption of animal fats increased by about 30 pen:ent. These trends do not, by themselves, make a st~'ong case that ~i/estyle factors are responsible for the l~e ~cy gap. Studies trying to ascertain thelmpact of measu~s to lower cholestero! have consistently demonstrated no impact on overall mortality, even when the interventions sucoess~ully lower cholesterol levels in the study po]~da- tions. Moreover, even iS we accept the most opl~anlsti¢ esti- mates of the mortality benefits for [ndiv~luals, the contfl- button of Iov,'er cholesterol levels on Ixrpulat~on life expectancies would I/kely be modest. One group of inves- tigators using the most optimistic assun~ptions esti.mated that, i/Amerlcans reduced fat consumption f~om 37 to 30 percent of the~" energy Lntake, pop~ation life ex~ectanc7 would rise by only 3 to 4 months. Fortunately, there exist betler data to help evaluate the extent to which cardiovascular di,~ase r/sk factors are responsible for intemaflo~l diferentials in [i/e eXlX'Ct- ancy. During the 1980s the World Health Organization (WHO) set up the MONICA proiect to monitor trends and determinants in cardiovascular disease across many coon- tries. This project provides comparable in/on'nation on cardiovascular risk factors for 52 centers in different coon. t~es. Early resu|ts from centers in C~ech Republic and Hungary a~ fllurrdnating and qnite contrary to the dictions of the risk factor approach. Cardiovascular morollty rates for males aged 35-64 in Budapest were third highest among the participating cen- ters, and second highest for females of the same age range. However, the proportion of males with serum cholesterol levels above 250 rniRlgrams per decil/ter was not espy- c/ally high° ranking only twenty-si~tl~ among participating centers. The proportion of males with elevated d~stol/c and systolic blood pressmes ranked thirtieth and th/rd respectively, while the proportion with l~:~sly eIe- oared body mass indexes ranked tu~enty-second overall. Th,~ proportion of fema|es with ~rmn cholesterols above ~ milligrams per deciliter and the proportions with ele- vated dlasto~ic and systolic blood pressures all ranked t~raty-fourth among participating centers, whi]e the pro- portion with grossly elevated body mass indexes ranked tc.~nhy-s/zlh. Only the proportion of ~,gular ciga~tte ~mohars, s~.th among males ~nd ]~fth among females, came close to Budapest's rank for cardiovascular monal~ty. In the Czech Repob[~c, can~ovasc'ular moa~ty rates were tu~h highes~ for males ~d thirt~n~ highest for fesnales among participating cent's. Howev~, the propor- Uons of males and /e~ales with elevated choleste~ls ranked ~rth and third, the pmportior~ with gn~ly v~ted body nms indexe~ ranked fm~rth and stv~th, and the 1~'oportions of ~ dgarette smokers ~ •nd tu~nty-~v~, ~specttvely. (Blood pressure mea~u~- m~ts had not yet been ~,,ported from the C.zech conte~.) These dat~ do not support a view that the East-West life expect~cy gap can be accounted for primarily by differ- e~ces in diet, obesity, or L~ck oi blood pressure control. It is trne that the MONICA dat~ do not take into account changes over time in the prevalence of risk factors or the possibility that intervals between the time of first expo- stue to a risk factor and the expression of di~,ea.se might m,xke it difficult to compare data s~oss countries. Yet they are the best da~ ~tly available and deserve capful =tt~nt~on on~ t~ter dat~ {not just more complicated ar~onen~s) are produced. The MONICA data do not negat~ the possibility that d/~fer~nces in cigarette smoking may be contrilm~ing to internat~onal diffe~nces in rise expec~n~. But how important is this? The crucial asl~-t of this question is tlKs: do factors other than c~garette smok~, which differ between coun~e~, serve to modify the behavior of a risk factor, such as ciga~tte smoking? In fact there is evidence of a regional effect which modifies the strength of the ~ssociation betw~n clgare~te smoking ~nd cardiovascu- l~r disease mortal/ty. The monograph ~ C.ountrL, s by A. Keys, which presents do~-~spon~e relatton~hipe between ~garette consumption and cardiovascular mor- tality for the United States, Japan, northern Eu.mpe, and southern Europe, dearly demonstrates th~ ~,gion~I effe~. The studies summarized in this monograph show very d~/ferent results by region: with a strong relationship in northern Europe and the United States, e weaker relation. ship in southern Europe, and no ~lationship m ]apan. Sh~dies.done in different countries ~L~fing cigarette smoking to lung cancer have shown simg~ coontry by country varist/ons in dose-r~sponse, as H/r~y~m= shows. The relation~ldp was weakest in a ~apanese study, where life expectancy is highest, but stronger in studies from the United Stet~s and Britain, where li/e ex~cy is lower, For example, a British study found that smoking ~) ci~- ~.-,ttes per day increased the risk of lung cancer 17-fold ative to British non-smoke~. A study done in ~apan found only an 8-inld increase. I/it is indeed the case tl~t dose-res]>on.~ reL~tionshipe vary. ac~s coun~es, then this might be due to factors other than just cigarette smoking. We must be cautious before att~buting the East-West ~ expectancy gap to estyIe factors. Underlying th~s apl:n'~ach is the ~ that the political, ~ia], and economic condRions in the East created • eli- matt of pc~vefless and alienation wl~ch ~imulated, in varying degrees, the conditions of deprivation ~ enced by the least privileged groups i~ the West. 11 BATCo document for Mayo Clinic 27 March 02
Page 24: 39000936
Table 2.7 Temporal re.rods in aSHpeci~¢ ,~,dloi,~ ~ rate* ]974]76.- Z97,Jj76,,,. Z97~[76- Z97,J[76.- +28.7 +~0.6 ÷22~ ÷23 -3,6 -23. -1.4 -~,7 -i9~ -34.t -15.0 ,,33,5 .43.3 -36.5 -33.0 -37,8 over, it must be assumed that these conditions ~ ev~ th~Sh the centrally-planned economies provided good Job ,security and relatively equitable distribution of Income aaoss a Wide var/ety of white and blue occupations. The corol~ry is bhat improvemenla in sodo- economic conditions will be the most effective means of ~,dudng the Ere expectancy gap. Furthermore, health problems assodated with poor l~estyle choices will not ~ much with dL-ec~ intervention until the nom/c environment hnproves. I/the East-West life expectancy gap cannot be thor- ougldy explained by po~duted environments, Inadequate medical ~ervices, or tifestyle risk factors, and cannot be d~missed as histodcalJy inevitable, how can we explain it? Here we explore the hypothesis that favors assoc~ted with the sodal, pollticaJ, and economic envh~nment~ social isola~on, perception of powerlessness, relative declines In the economy, and increasing social class gradi- ents in health statt~ and well-being--are contributing to the life expectancy di~erent/aL Admittedly, there is little data from Central and Eastern Europe with wl~ch to test th~ hypothesis. Yet the hypothesi~ deserves adequate exposition because In many ways [t explains international d/fferences In health stab~s better th~n any other approach. The hy'pothesis, ~d~y stated, is as follows: following impressive economic 8rowth during the two decades lowing World War 0, the countries of the East ~ve|y reached the top of the national income/life ex~cy curve (i.e. the point at which further increases in national per capita income would I~kely have only limited impact on national life expectancies). Thereafter, despite continu- Lng economic growth, the authoritarian character of the cour~h'/es of the East became a~ obstacle to.~'urther g-ain~ In health status, and the We expectancy gap began to emerge. As in other hierarchical sod~d es, large soda] class differences in health and well.being emerged. In addition, the political r.lin~te in the East led to an IncreasIng percep- tion of isolation and powerlessness, par~cularly among Pol/tica[ly d~~ groups in society. The concur- rent dedinain both the economic and soc~ environman~ are now reQected in steep social clas~ gradienl~ In life expectancy and relatively high rates of mortal~ty ~rom car- The discu~ion below follows the sequence of asser- ~ons in th~ hypothesis, presenlLng evidence ~m around the world to support the plausibiUty of each, and where lX~s~ble, corroborat~g evidence f~m the East. Preston, in Morality Patterns in National Populotlon~ (1976), shows ~at until the 1930s, per capi~ national income was closely correlated wlth l~e expectancy around the world. Sign~canfly, between the l%0s and the 1960s, the weaRhiest counties in the world ach/eved a Po/nt at which dlfferences In per capita nadonal matc~ d~erences in l~e expectancy, even though there was a three4old per capit~ income range among them. As mentioned earlier, several counties in the East ~ad reac~ed levels of ~He expectancy which were s~ to tho~e of the wealthiest Western ¢oun~es by the early 1960s. According to t.he iste~t ava/hble information, there is still no con'elation between per capita national income m~d l~e expectant7 among OECD coun~'ies. However, ~e expectancy d/fferences among theOECD cour~t~es appea~ to be closely assorted with incom~ d~sh'ibutlon. The OECD coun~Hes wl~ch have developed and m~in~ned the mo~t egallta.Han income dish, buttons l~ve experi- enced the most rapid gains in l~e expectancy between the I~0~ and the 1~80s. ~oreover, OECD coun~es with rela. t~vely ega~tarian income d.ism'butions {L~ Sweden venus Grea~ l~dtain), also had h~gh overall l~e expectancy and much sma~er ~mdients of decUning I~e expectancy across groups (Le. the British cla.ssi~cation of occupational class applied to both Sweden and Britain). These ob-.~rva~on~ su~,est tha~ the health h:npact~ o~ a sense o~ relaffve depdv,,tion, of bein~ at re.lation to thos~ be~er off, extend beyond the b~pact ~tst ~nelafive ~n~ome. Sha~e~ which have looked at the Table 2.8 In~tnt morta~ty .tet ~d not compile p~ Complet~ B~¢ v~a~o~ 14.1 ~nds~ or ~st-~ondm~ 12,2 ~sh~ (Le, u~v~i~) 10.6 ~0 BATCo document for Mayo Clinic 27 March 02
Page 25: 39000936
~me ~on ~ ~d ~ ~t ~ely to ~ ~r fa~. ~, a~g ~ ~ W~- Pond. H~. ~d ~e ~ ~mlo~ ~d ~, by ~ion, o~ OE~ ~m ~ ~ ~ly I~. ~no~c ~dien~ ~ ~e ~s ~t ~ of ~e h~h ~pa~ o~ ~flve d~va- y~ o~ ~g ~pl~, or q~e of ~e ~ io~d ~ ~ ~d~l ~m whe~ ~ ~ve ~ done I~g ~no~c ~adien~ ~ heal~ s~ ~ve ~e~l ~aant c~ra~e~. F~t, ~noto~c paRe~ of d~e ~ ~e ~ ~th d~g ~no~c level, ~t ~on of the "p~eg~" ~m the "~d~eg~." ond, ~e ~dients tend to ~ st~r ~ong m~ ~n womb. ~, ~e ~di~ ~ve ~m~t~ f~ d~d~, ~ though the p~pal ~ of wo~s, ~e fa~o~ p~u~8 th~ ~di~ ~ to o~ate ~ugh pathobiolo~ml m~ ~t m not ~que to s~c d~ea~ but, ~er, ~uen~ ~ugh m~sms ~dam~l ~te~8 ondi~o~. ~u~on level ~ ~ely to ~ the ~i s~ ~tor m~t ~ for ~mpa~ ~n ~t ~d Wmt. ~e alt~fiv~, ~me and ~Hon, a~ a~c. ~e~c~ ~ the level of mon~ ~m~fion for different occupations may make both hou.~ehold ~u~fi~ ~el ~ s~ngly a~t~ ~ ~d ad~t mo~ ~ Po~, H~S~ ~d ~e ~ ~mlov~, ~e ~ ~h~ ~ ~ ~e ~st for w~ ~y da~ m a~ble. ~ Pond ~ 1~7, ~ was a n~ly ~fold mo~ ~dimt • e o~p~g of ~e m~t ~ l~t ~u~t~ wom~ mint OE~ ~ ~e ~t mo~ ~dient Ttble Z9 ~ ~o~fion on ~ ~t~ ~u- ~ o~ ~u~on ~ ~e h~ m~ ~. ~e ~ble sh~s age a~ ~ s~c ~ y~ of ~m~g a~ for ~p~ ~ ~ ~d ~. Mo~ ~t~ vaW ~y ~ ~e mint ~d l~t ~u~t~ ~1~ ~ ~e fo~~lova- ~, ~ of age. ~e ~e~ y~g~ ase ~, ~ ~e sap d~g st~y ~r m~te a~ ~u~ ~n th~ a~ among ~. We ~ve ~n t~t d~c~ ~ ~iov~r ~ mmp~ most of ~e ~st-W~t d~l ~ mor- ~iW. ~ o~ for the ~n~c ap~ch ~ible, it mint ~ able ~ ~p~ ~e va~fio~ ~ ~r- ~a~r mo~fi~ w~ch de~nd p~paOy on ~n ~t~ to ~ quaB~ of ~e ~1 ~t ~d to su~t ~t ~ ~0~ ~ the ~1 ~y ~ ~nt to h~l~: ~ono~c ~ndtfio~ ~d~, ~e qua~ of ~1 sup~ and ~h~v~s ~ one's ~, ~d ~n~o~ ~t~ ~ ~e work Table 2.9 Ase-spec~c death rates (per 100,000) by level of edu~ttton in the Czech Republic, 1979--1982 ~0--34 438 151 89 77 5.7 3~-39 579 244 155 117 4.9 40-44 814 ~ ~8 ~ 4.0 4~9 1167 ~ 4~ 3~ 3.6 ~ I~2 1055 ~ 628 Z6 30.-34 i17 $2 &3 38 3.1 35-39 13~ 10~ 92 76 1.8 ~ 222 "IM 144 I~ 1.4 4~9 331 ~1 aIO ~1 I~ 0 BATCo document for Mayo Clinic 27 March 02
Page 26: 39000936
Several studies have demonstrated that ch/Idren ing up in poverty in affluent soci~es are n~re ILkely to dle ~mm heart disease in adulthood than those who g~xr, v up in ~reater affluence. However it is still possible that nutritional ~nd lifestyle differenc~ are responsible ~or the increased mortality risk rather than the Iong-t~'m impact of mhtive deprivation opening through novel b/ological pathways (for example, suppression of the immune systen0. The best evidence available addressing this question comes f~om longitudinal studies of working populations in Britain and Sweden. The British study focuses on civil servant; a particuiary good group to study because their work is generally not physically dangerous and the dlvi- sluns between the occupational ~ades ate quite rigid. This study found that persons in the lowest grade (man- ual), were three times more likely to die f'~m heart disease than those in the highest grade (adn'~'tistratura), with the intermediate grades (professional and clerical) falling In between. The crucial lesson from th~s study ~s t~at the g~d~. ent remain~ largely uncl~nged af~rr account was ~ of smoking, s}/stolic blood pressure, and plasma chol~teroL In other words, the risk of coronary heart dL~ense mortality could not be explained away by parallel gradients in tradi- tional coronary heart dlsease risk factors. l(arasek and Theorell (1990) looked at the relationship between job characteristics and the prevalence and incl- de~ce of coronary heart disease in Sweden. They found that workers who sald their occupational environments were psychologically demanding and provided little lati- ~de to make decisions were at greatest risk for develop- ing heart disease. Lack of social support outside work increased the Hsk. Astudy which examined 7,219 working men over a period of n~ne years found that those who reported poor so<~al support, excessive demands, and poor decision latitude at work were twice as likely to die ~om cardiovascular disease than others. These reeults are consistent with studies done in North AmeH~ on refa- fionshIps between social support and mortality and on relationships between per~ona[ control and health and hess. Not surprisingly, most of the }obs classified as "poor support]excessive demands/poor decision latitude" were assodated with low socioeconomic status. The final element in this approach concerns the role of social support in protecting against heart d[.sease mortal- ity over time. There are many studies wh/ch demonstrate lhe rote of social Lsolation. independent of working condi- tions, as a risk factor for premature mortally. Most rele- va nt here are thc~e that deal with the quality of social sup- port networks in well-defined communities, and the best of these is the SO-year stud), of the population of Rosetu, Pennsylvania, which hacked mortality ~rom myocardial L'~arctions ~rom 1935 to 198,~the basis of the ~Roseto e~factY Roseto was a homogeneous Italian-American community which had s~kingly low mortality from myo- cardial i~arction (heart attacks) relative to surrounding con'~nunities. Beginning in the 1960s, the pattern ol~ low mortality broke down, prin~rliy affecting men under the age of 6S and elderly women. This corresponded to a period of erosion of cohesive family and community rela- tionships. Remarkably, dorlng the 30-year period of reh- 14 lively low mort~IRy them was no evidence o~ d~erences between Roseto and the surrounding communities in terms of any conventional heart disease Hsk factors, fn fact, it was during the period of increasing prevalence and accelerated death rate ~rom heart disease ~hat there was a s~ng reduction in the consumption of fats and oils by Rosetans. Social coheaiveness and social support are the protective factors which best help explain these remark- able trends. Have the working and living conditions of Eastern Europe over the past tbsee decades featured poorer social support, more tiemands, and less Personal decision hti- tude than in the West? It is possible that they have. Lack of individual ~-doms and liberties, overly centralized "conunand" economies, working environments infiltrated by police agents, and endless difficulties obtaining basic consumer goods may well have added up to more stress than faced by those with undesirable working conditions in the West. Yet, for the most part, we have no data to sup- port this assertion, and, because of the political and eco- nomic changes taking place In Eastern Europe, it will become ine~asingly difficult to evaluate in retrospect. A case study from Hungary illuslratea this line of rea- soning. Hungary is an interesting case because it has the worst health status in Central and Eastern Europe, yet does not have the severe pollution problems o~ Poland or the Czech Republic. Interesting Information on health inequalities within Hungary and other European countries has been pre- sented in Health InequaliHes in European Countries (Fox, 1989). In each country where it was looked for, there was a strong declining gradient of mortality with increasing educational level for males and females aged 35 to 54. A similar pattern was found for Hungarian males, although at each level of education the respective mortatity rate in Hungary was higher than in the comparison countries. However, mortality for Hungarian women did not exhibi~ the same pattern. Beyond 12 years of schooling, mortality rates actually increased, and Hungarian women with uni- verslty educations had a mortality experience much like those with less than 8 years of schooling. Mortality data /'or Czechoslovakian women pr~ented earlier also exhib- its this pattern, and is yet to be explained. Within the city of Budapest, there are large differences in male li~e expectancy between the districts with the highest and lowest levels of educational attainment. When male life expectancy at birth by district is con'elated with the proportion of each district's males over the age of 25 years having completed less than grade 8, the relation- ship between the two is very strong (correlation =- -0.87). In addition, the areas with highest li~e expectancy are in the green belt, while those with lower fife expectancy tend to be the most depressed neighborhoods downtown with many economic, social and pollution problems. These life expectancy d~erencea are based primaKly on mortality a~ter the age of 30, and cut acres ahnost all chronic dis- eases. In particular, mortality rates for men between the ages 40 and 45 are 3.3 rimes higher in District 7 (a depressed downtown area) than in District 2 (a green belt area}. This pattern is apparent for other districts as well. BATCo document for Mayo Clinic 27 March 02
Page 27: 39000936
Districts I, 2, and 12 are relatlvely privileged compared with the d~erioratlng downtown areas of Districts 6, 7, and 8, and suburbs with low educafiora] atta~nent such as Dbtricts 17 and 20. In the age group 40 to 5~, the ~ in mortality rates for cirrhosis of the liver, suicide and stomach cancer range from 2 to 10 [old acro~ these districts. There is evidence that the ~dlent betwee~ sodal and in/ant mortality and suicide in Hungary b becondng steeper. For example, in 1~o5 there was a 1.8 fold di~e~nce in infant modxlity between the offspring of women with the least ~rs~s the most education, hut by 1980 ~ had g~'own to a ?.8 fold di~erence. In absolute terms, there was no improvement ~ the infant mortality rate for women with h~r.s than eisht years of schooling, while for women with more than 13 year~ of schooling the mortaI~ty rate by 50 pe~'cenl. The s~icide xate follows a sh'nllax pattern. In 1960, the suicide rate for blue collar workers was tv~ce as idgh as for white collar workers, but was ~ dines as high by 1980. D'~ring th~s l~-iod, the overall suicide raw in Hungary doubled, and the morta[Ry rate ~rom d~hosis of the Liver ~iulnhspled, a~ter remaink~g stable f~om the end of World War II unti.1 the Soviet invasion of 1956. By 1980, there was evidence that paten~alistlc rule had [eft animprint on people's sense of power and ir~uence in society. According to a survey done in the late 1970s, about 50 percent of the adult population in the developed cou~- tries believed they could do soraeth~g at the national level to protect theh" inteJ~StS..Among Venezuelan and Turldsh farmers, and Mexican non-a~ricu[turel workers in the developing world, this percentage varied between 20 and 38 percent. In Hungary in 1985, only 10 percent of the adult population surveyed believed that they could do something to protect theLr ~terests at the r, at~onal T~u'thermore there are data showing a tendency towards distrust and social isolation in Hungary compared to Western European countries. The European V,,lu~ Sysfnns .Study, which was carried out in Western Europe in was exteuded to Eastern Europe later in the decade. Com- pared to respondents ~'om trine Western European nations, Hungarian respondents reported less to s~crifice themselves for people outside their less wiAlin~nees to sacrifice themselves ~or their ch~dren, less willingness to teach their children resi:~'t for other people, and less willi.ng'ness to emphasize lo~aliy and faithfulness as child-rearing principle~. These Rsulis raise the qoestJon of whether or not the "Ro~-to e~ect" might [~ve be~ operating in reverse in Hungary. A Reappraisal of the Determi~nta of Health in Central and Eastern Europe As Thomas MdCeown showed in his analysis of the or/- gins of the decline in mortality from infectious disease in nineteenth and twentieth century BHtain, we have shown that the traditional explarutt/ons for the llfe expectancy sap are not as important as had been thought. S~l, we have not been able to demonstrate dearly the rdative ~n~or~nce of the most important factors. For Mc[C-own, it ~y ~ve ~n ~d~y ~g to ~te new ~ of ~qu~ a~ ~ on ~e role of varies d~i- ~ts o~ h~th o~ ~e. ~r ~ ~ ~en- ~l ~B~ ad~ce, howler, such en oulc~ ~y ~m ~g. ~t ~ w~ld not ~ a c~ ~m~t. We ~ m~ ~nd~io~ ~t ~ help ~t ~o ~ve ~e ~ of ~t on health in C~al and ~e idea t~t en~mnmen~l ~Huflon in Cen~a~ and gap ~n ~ d~. ~though ~ a~on ~ ~ made d~y, it ~s ~e~ as a ~u~ ~e ~x~t~on of fi~ and phot~phic ~ h~l~ s~, ~t~d, ~~! ~HuHon ~n~nt~t~oneofa~ dete~n~ o[ h~lth. ~d~ ~e o~y ~sb for ~[e ~mpa~ of health s~s. It b silent t~t the ~flve ~ ~ a~s of Cent~! ~d ~s~em Eum~ ~ ~ely to ~ o~ the ~y avoidable deat~ or ~le ~o~ ~ch as diet, smo~ and ~. S~d~ ~ to ~u~ ~l- d~ a~ ~Wle fa~. ~ the ~b~ ~d, ~u~8 ~u~on ~] alm~t c~l~y ~u~ the b~en o~ dis- ~ and morbid/W, ~nd ~1 ~p~ve ~ua~W of ~ ~ on ~ ~ds. F~y, it ~ ~mnt to ~ ~t hu~n health n~ ~S pm~ as a p~l ~t~ for en~en- ~1 ~te~en~on and ~ ~g ~ of any ~ ~t en~l ex~u~ a~ the p~ d~e~- ~nt of health ~ ~e ~on. ~e cla~ b, ~er, ~I ~u~on, h~n h~l~ ~s am ~s silent, not morn silent, than aW other. Notes I. All me, surements of particulate matter have been converted to PM~0 ~ing conversion factor~ pr~ented i~ O~t~o a~d Hughes. 2. This ~esult is obta~ed as follows. [n the perio~ 19~)-74, the mortality rate di~erence fn~m medically avoidable ¢au~ was 31.4 per 100,{XX) (~01.0 - (~.8) and in I985-87 it was 37.5 per ~00,000 (72.5 - 35.0), ~n anise o[ &! l:er ~00,000. In 1970-74, the morality r~te difference /tom medically non-~voldl~b{e caum was ~7.9 per 100,000 (~,-,-~.1 - Z06.2) and in I~85-87 it ~9.6 per I~0,000 (35~.6 - 25:L0), ~ L'~se of 61.7 per |00,000. Thus, the total (re}atlve) Increase In mortality rate in the ~ormer Cz~,ho~lovaY,~ oompared to En~land and Wales b 100,000. o~ which on]}, ~.I, or 9 percent, can be att~buted to medlcal~y avoidable causes. 15 BATCo document for Mayo Clinic 27 March 02
Page 28: 39000936
Chapter Three Health and Environmental Pollution ~ chapter analyzes the Fast two steps of a fi:~u--~tap ce~ to reduce health damage from environmantal pollu- tion in Cenlral and Eastera Europe. The four siel:~ a~:. i) Iden~fytng human health problems a,~ociated wRh envh'onmental pollution. it) Making generalizations about the, prhu:ipal ty~s environmental pollution affecting human health. iii)Compreher~ively identifying place~ where popula- tions are exposed to ~e types and levels of pollution. iv) Dev,,~oplng a remediation strategy for those places. Information from countries in the region, while o~te~ incomplete or bis~l, has revealed the major health prob- lems meat likely to occur h'om exl0osu~e to envi~ental pollution. This has allowed a generalization abo~t the principal types of environmental pollution affect~g human health in the region and the types of expo~ttre sce- narios wherein human health will most likely be affected. [n ~m, this has made R possible to answer the question: "What other places in th~ r~&ion are like th~ pla~ wh~r¢ ~n~i- mnmental pollution has b~en docum~nttd as ha~ing human health, but for ~ohich no human h~alth ev~ence is able?" Th~ is a crucial question, because answering it allows the environmental action p~anning process to go horn ~he second m the third step iden~2ied above, and comprehensively idenlffy populations who~e health may reasonably be expected to be affected by environmental pollution. Below is a summary of the existing information show- ing locations where human health is l£kely being by ex~ure to pollu~anta, a~co~ding to criteria de~'ibed below in Methoda of Data Evaluation: a) In 37 locations in 7 countries, lead in the air, watt, roll, and food was h~und at levels Mgh e~o~gh to cau.~ neurobehavioral defidta among children. dence of neurobehavioral deficits h~ been found in .~veral of thes~ place. b) In $3 locations in 10 countries, aoate re~ph'atory and irritant condRions, such as sinusi~, phaxyngRls, 16 bronchi~, and conjunctivitis, were associated with aixbome exposur~ to du~ts, sulfur dioxMe and oth~ gases. c) In 35 locations in I0 counties, chronic respLmtory conditions, primarily chronic bronchitis and asthn~, were associated with alrbome exposth-es to dusts and gases in an epidemlologically credible manner. d) In 8 locations in 3 countries there is evidence of excess mor/ality in relation to environmental poilu- tion, particularly between lung cancer and air poilu- tion, and L~ant mortality and air pollution. This Is based on direct evidence. e) In 19 locations in 7 cotmtri~ there is evidence of abnormal physiological development associated with alr pollution including abnormal pulmonar~ hematologic, or immunologic development; growth retardation or congerfital anomalies. 13 In 6countr/es, there is evidence of widespread nitrate concentrations in drinking water high enough to requi~ water ~ephaceraent to protect newborns aga/n.st methemoglobinem]a, or where morbidity and mortality from methemoglobinem/a is endemic. 8) Oiher, less frequently occurring problems, include exposure to arsenic in air and water, infectious dis,- ease outbreak~ from microbiologically contami- nated drinking water, increased incidence oF thyroid cancers in some commun/t/es following the Chef- nobyl accident, incidences of fluor~is due to expo- sure to emissions ~rn aluminum smelter~, and dlsease~ associated with exposures to chlorinated hydrocarbons and pesticides. Annex 4 of this volume contains a complete list of local- ities In Central and Eastern Europe whe~ these problems have been documented. The pollutants having the greatest impact on human h~alth status in CenWal and Eastern Europe are:. • Lnul in Air and $o//from emissions from lead and zinc smelters and, In certain cities, em/ssions from trans- port due to the use of leaded fuels. BATCo document for Mayo Clinic 27 March 02
Page 29: 39000936
• Airborne Du~t from coal burning in household fur- n~ces, small-~c~le enterpri~s, power and heat plan~, and me~allurgical plants, • S,l~r Dio~id~ ~nd otl~r Ga~ Imm power industrial plants, and bouseholds burning high-~ulfm' co~l or hlgh-sulfur ~uel oil The follow/rig pollutants have been defined ~s sec~ndo m7 because they are, on average, less p~'ewlent involve cI~Lms of causation that are less certain ~.the ones above. • Nitrat## in Dr~n/dng Water £~om inadequately t~inedldesi~ned or improperly located rural sept/c t~nks, fe~l lots and agricultural enterprises, and inap. propr~ate tertillzer appl/cation. • Cont~mlnants in Fo~ from the h~pproprlate han- dling or dislz~al of lead dust, heavy metals, pesticides, polycycl/c arom~t/c hydrocarbons, and chlor/nated organics such as PCBs. Many of these substances have well-documented toxic properties, yet the human health $ignLf/cance of ingest/on at hrgely unknown doses uncertain, • Oiler Contamlnants in Water fi~m the/nappmpfiate handlin$ or disposal of water contaminated wl~h arsenic, ,.druses/bacteria, pesticides, radionuclides, ~nd r.hlori- nated or~nies. Waterborne arsenic and v-L,~uses/bacteria have been directly implicated in a number of episodes of human disease in the region. The other contandnant~, like their counterparts in food, represent risk~ of unknow~ prevalence, magnitude, and certainW. Tl~ee ~sues are likely to be sou.rce~ of concern for ~ome observers. These relate to (1) the relative importance of dust versus sul~r d~oxide and other gases~ (2) the relative importance of a~" v~sus water pollution in tem~ of cur- rent impacts on human health; and (3} the level ot preci- sion and coherence of the priority poliu~ant categories, from a toxicological pe~spectlve. D'osr VERStlS ~AS~. New knowledge is rapidly emer8- ing about the impact of air pollution on human health.The role of certain ga~ and vapors {especially ~ dioxide, oxides of nitrogen, ozvne, and hydro<arbons) in precipi- rating acute respiratory episodes and exacerbaling chroRic bronchitis and asthma/s being eludda~ed. At the same time, the impacl of respirable dust on mortality {in addi- ti~n to Its role In resp/ratory morbldi/y) is heine mcog- nized from studies of a variety of major, urban centel~ the West where ambient dust concentrat/ons are much lower than tn many places in Central and Eastern Europe. In practice, the llst of places in the region with hun~m health problems esso~ted w/th a/r polIu~on include many where the prJ~'~3, problem is dust; some whe~ it is one or more gases or vapors; and many where the prob- lem b a combination of the two. Am ~.~urs W^T~. Airborne Pollution b ~tlm~t c~- minly ~ ~reatez thrmt m human hmbh ~ wateflx~'ne pob lu~on ~n Cmtral and ~stm'n Bu.mpe. Polluted air is l'~a~der avid than Pol]ut~l wa~. T~us, any c~mtry w~ ~ ~ ~ve ~ ~t ~ ~ ~ h~ ~ ~m ~ple w~ ~ve ~ ~ ~ne, ~e ~t~ ~e ~b~ ~ ~ of ~r ~ q~ ~r ~ ~Hu~, ~ ~ ~ m ~ve morn ~ av~ble w~t ~L ~ ~e ~side ~e o~y al~ve to ~ O~ ~ CA~. ~me o~ the ~ ~t~ w~ ~ve ~n u~ h~ ~y ~m v~ b~d, at l~s~ ~m ~e ~m~ve of ~m~t and ~olo~c to~col~ ~ is ~ h~lth, on the one ~nd, ~nd the n~ of m~g ex~ s~ ~t~o~ w~ch ~ pra~l ~m the ~ve mm~n, on ~e oth~. For ~tance "d~t," t~u~h ~ ~ ~on ~I~ of i~ o~, ~ ~ve ve~ d~- ~t h~lth ~pa~ d~g on i~ phys[~I and l~l ~m~er. ~, • mm~ia~on s~ w~ch ~ #d~ ~ght ~ ~a~ly h~emge~ to a ~in~l ~um ~n Y~ ~ dust de~ a w~ ~ ~ent f~ ~te~en~on, s~ch conce~ ought to m~ ~th ~emn~, ~th ~m ~e ~v~ent ~m- m~ and ~ ~e b~d ~eld of pubic h~Ith. Me~s of D~ ~te p~l~ with the q~ o( epid~olo~ and ~ ~m~t ~ Cent] and ~ ~ ~ I), ~em ~ ext~sive e~dence t~t en~enml ~u~on ~s ~d an ~pa~ on the health s~ms of the ~on. ~ ~e quall~ o~ the ~vai~ble e~dence va~ ~ mu~ ~m l~tion to l~afion, it ~s ~n ~ to deveIop a s~I ~t of ~te~ to ~ ~o~ e~ si~o~ w~ch ~ve aff~ ~n h~th ~m ~ w~ch ~ve wh~an ~ b ~t~ ~th a h~n h~Ith lem ~ a ~er ~tent ~ the ~ of weU- world, ~d ~h~ si~o~ ~ w~ ~e o~ a~ ~flon ~ not ~ ad~tely s~di~ e~whem ~ ~e ~) ~ ~ valid e~s~ 2) ~ ~e ~ ~v~ ~8h enough to l~d ~ on h~n h~Ith? 3) h ~ d~ e~d~ce of an eff~ on h~n ~ the l~on ~der s~dy? ~w~b "no" we ~n ~n~ude ~t R ~s noL whm ~e ~ to ~e ~t qu~on b "yo" and BATCo document for Mayo Clinic 27 March 02
Page 30: 39000936
answe~ to the second and thlrd Is'no" it Is mncluded that hunan heflth I~ not bee~ affecte~L The other conflngen- des fall somewhere between an unequivocal "yes" or ~o" and require ¢arehd s~'ut~ny on a ¢~e by ~se basis. For the pur[x~es of identifying prlortt~es for dean-up, uncert~n c~es l~ve usually been re~olved by "not re~t- In~' them, that is, by pmvision,~y concluding that hun-~n health h~ been affected. a~'ted by pollution in a w~y which has not been demon- ~t~ated by previous re~u~ arour~i the world, the evalu- a~on ts more difficult. The fl~-Jt step is to a~k whethm" or not sufficient ev/dence exis~ regarding the specific claim in ~ location of interest to meet traditiorml epidemiolo~ic crlterla for causation. So far thb has n~t occurred, not least because it b dff~-ult to suslain a claim of causation with- out consistent evidence from several places, rather th~n from just one, The next step is to ~ whethe~ or not the dalm is plausible on the basis of w~t we know about human biology and patholog~ If it b not, then the claim can be ~-jected. If it is plausible, then the final step ts h3 ask whethe~ the erpoeure is suffidently intense anti unusual by Western standan:h to have escaped detection in throe countde~ where the epidemiologi¢ study of the effe~ of ind~txbd pollution Is mo~e advanced than in Central and Easte~'n Europe, If the answer to this latter ques~on b "ye~ then the claim is provisionally accepted. This decision algorithm is illustrated below. Agent of Human Is therevalld ~ exposure data? ~ Is exp.. ure high eno6gh for human heal~ impact? Is there evidence of human health impact? Does the m~ationsht~ No ~ meet accepted criteria for causation? Y~ No Y~ Y~ N.~ No Y~ No No biolo~i~lly plaus~le? Do Not 3 Other Combinations BATCo document for Mayo Clinic 27 March 02
Page 31: 39000936
The Geography of EnvlronmenSal Hearth Conditions ~ ~e ~, it ~ as ~ugh en~nmental ~I~ le~ were concen~t~ In ~e a~as o~ ~olo~ which ~em ~11~, ~mewh~t l~ly, hot s~ts. ~ m~el for this was the ~towice ~ton of Poland. and ~e ~s~ of no~he~ ~hem~. From t~e stand~int of envi- m~ental action the m~t im~nt c~m~e~tic fa~e areas was t~ fa~ t~t air qua[iW pmble~ w~ not !~1~ or easily attdbu~ble to a s~ll num~ of ~llut- inS plan~. Instead, the air sh~ was ~/ng f~u~, more or l~s u~o~y th~sh~t the ~gio~ by h~- d~s of ~t and non-~int (p~adly ene~ ~ m~l- lu~i~l) sou~ in the area. ~s wo~d ~ply ~t any ~rat~ for improving ~io~l air quafi~ would ~ckle whole ~o~ of the ~onomies o~ Poland and the ~h Republic in o~er to have a s/~i~cant Impa~. As Invesfigatic~ pr~ though the ~s~ of Cen~l a~ ~stem Eu~, it tu~ out that the h~ s~t m~el was not n~Hly applicable to other place, lmtead, we found smeller a~as like ~ CounW in Hunga~ or C~p~ Mica ~lon In Romania which a~ mmin~ent "~st ~lt" a~s in Ame~. Th~ a~ old ~du~Hai a~ wh~ the nearby ~lation is ex~d to emi~/o~ a ~nfiuence of ~int sou~ whose infiuenc~ on air and wat~ ~n largely ~ d~ffn~h~ from one anothec sugges~ that an a~on plan which targets s~fic ~u~ ~11 ~ve ~me chan~ of tmp~vinS ~th en~en~l q~lity and human health. ~nally, some of the ~st drama~c en~nm~tal health p~blem~ have eme~ in I~ations whe~ "bad town p~nnlnfi" ~s augment~ the impact of ~m a single ~int sou~. ~d town planning s~ply m~ns that housing or fa~s a~ I~at~ fight n~t to ~lluting plant with no cordon ~nitalre to p~t~ them. In such ~ an effe~ive envkonmen~] a~on strat~ ~ to ci~e the plant, elim~ate the e~s[ons, or abandon U~e ~uslng/fa~. An example of each o~ the~ ~ of [~aHo~ is siren below. ~h~n~, CzccN ~ublic Hie ex~an~ over the past ~ yea~ for mal~ and ~emaK~ In no,hem ~hemla ~s lagg~ ~hind the (he count. ~e dist~c~ o~ ~offhem fiohemia a~ beaH[y ~p~ent~ among those with the hlgh~t mo~lity ~ the ~h Republic for lung cancer (as well ce~), ca~invas~lar di~as~, suidd~, infant mo~afity, ~pirato~ disease, and "extemal" ~u~. ~e physical and chemical envim~ent of no.hem ~hemla ~ uniquely h~tile. ~yane who v~its the mi~ ing distH~ of TepHce, Usti ~d ~m, M~t, ~n, Ch~utov will ~tn~ the in.mental elf.s o~ ofo~-plt ~ning and effluents ~m a vaH~y ~I con~o~. When e~ssio~ ~m ~me heatinS am ~m- bfn~ with industrial ~ssio~ ~ th~ mounta~ va~eys during temperature lswerslons, high ambient concentra- tions of sulfur dioxide commonly occun Concentrations of ~-e~er than l,l~0 micrograms per cubic meter c~n be sus- I,~,~I, on avenge, ~r 24 houzs at a t~me or longer. High ambient concentrations of dust also ~juently occur. Both rain water and dust in th~ area have l~en found to contain complex mixtures o(metals, organics, and polyc~clJc aro- matic hydrocarbons. Several types of human health problems have been associated with the environmental conditions in the area. For example: • Mortality from respiratmy causes among newborns 1-12 months old is five to eight times higher in the a~eas o[ highest ambient dust and sulfur dioxide levels com- pared with places where alr quality mee['~ standards. • Rates of tow birth weight and congenffa[ anomalies are suspecled of being increased among newborns. • Allm~ie~ and n.~piralory diseases a~e more prevalent amnng schnol child~,n than In the r~t of~e ~ Republic. • Children temporarily removed from the area to attend "nature school" in an unpolluted area have shown evidence of improved hematologic function, which reverses when they return home. • All-cause mortality and mortality from lung cancer Is higher amoog both men and women compared with the Czech Republic as a whole. A Town at lhe Con]htence ofPolnt Sou~c.es of Pallut~n--Col;~ Mica, Romnn~a Col:¢,~ M~c~ is home to several poorly maintained industrial facilities, among them two ot" t~e s~.~ion's mo~t notorious |ead sme|ter~. Health problems of particular inter~t in the community include respiratory probl~'us ~'om ex~osu~ dusts and ga,s~ and neuro~ehaviorn[ problems due to expo- sure to lead. One study examining pulmonary ~mction In 37I Copsa M/ca children ages 7-H showed that of the exposed chf[dren, 30.2 pe~ent had reduced peak expiratory flow ~tes and 18.1 pe~ent had n.~cluced forced expiratory cal~clty coml~as~l ~lh 10 pen:ent of cMIdren not eXlX~sed. The same group of chiMren, along with a Stoup of 12o year old exposed children, were siren a variety of ~ych~- metric t~s~ Io determine whether or not lead was damag- ing health, Children ~ to low levels ot'lesd may suf- fer neum~vlora| damage, including lower shortened attenlinn spans, hy~x~ract~it~ agg~sive behav- |or, reading disabilities, and behavioral problems. Much higher ~ercentages ~han exl'~-'cted tested weak or very weak on among the ex~:l cl~ldren. While approximately 30 percent of children were expecied to l~t *'weak or very weal~" meardng below the fttst st~ndarcl devbtion of the "normal" distribution, 73 percenl scored at this level on the LQ. test, .~ ~ercent on the concc~ntratinn test, 52 I~tcent on the learning test, and 6(3 l:~..~t t on I~e memory "Bad T~ Pl,,nn(ng'..-Dimitro~grad, Oulgari,, In I~mil:zovg~d, thick, acrid effluent containing hyd~rogen fluoride ,~nd hydtagen sulfide comes bmm a .ltngle smo .ke BATCo document for Mayo Clinic 27 March 02
Page 32: 39000936
stack at a fe~UZizer phn~ Hi~h.r~ apartments and ~ ~ ~ ~ l~e~ of ~ ~o~ A ~ ~ ~ n~ of ~d~n ~ ~d ~ve ~ow ~ physi~ d~elopm~t ~d ~ ~ He~ Problems ~at~ wt~ ~e ~en~ ~os~s ~ ~e Re,on ~ ~n p~ the ~den~ w~ su~ ~e ~ncluslon t~t hu~n health ~s ~ aff~ ~ ~- m~en~l ~llufion ~ Cen~l and ~stem Eum~. It o~a~ a~o~ing to the p~pM ~ ~t~o~ d~ p~ously. ~u~ to ~ ~u~ [o even Io~ do~ o~ l~d ~n ~ ~b~e b~ damage and Iea~g p~ble~ ~uding lower ~pa~ a~enHo~ ~ and ~n~ga deE~, and ~havior d~e~. ~ de~ a~ si~t ~a~ they ~y ~ve long-~e~ ~s on ~'s s~ o~ ~ Evidence o~ ~~l de~d~ amon~ ex~ chi~ ~s ~n fo~d ~e~r ~d~l ~t ~u~ o~ lead (~[ly smelt~) and in u~an a~as ~th hea~ ~a~c Avenge bl~ lea~ l~e~ amoag ~ child~n in Cen~al a~ ~stem Eum~ a~ o~en ~at~ t~n ~a~ ~ d~i~er and ~m~ exc~ ~ ~ ~he W~t un~l ~en~ yea~ ~go, bul a~ ve~ high b~ t~a~ standa~s. For ~sta~ce, the hlgh~t av~ge lead level ~ a [~I co~u~ ~ Canada ~ ~e~ measu~ in a smelter town ~ith pa~larly unfavo~ble me~]o~cal ~n~i~o~, was ~3.~ mi~ ~r d~- [Rer among a ~mpl~ cents o~ the to~'s ~ y~r [n Va~couv~, a ~ o~ I~ million ~th ~o lead~ ga~ne {or ~[e and v~aRy no other ~in~ sou~ o[ lead, the average bl~ lead l~e[ among 2-3 year old~ ~as 5~ In s~di~ In ~he W~t, it ~s ~ ~hown ~t ~ ho~ d~t a~ ~anl sou~ o[ lead ~ to c~- d~n, ~ally amonS th~ y~g ~ough to ~ p~g on the ~und, mouths thek toys, and ~ ~ d~ ~nds. ~il lead concen~a~o~ ~ c~ a~as of Cen~l and ~stem Eu~ may ~ welJ a~ve ~ceptable leve~ [or ~iden~al areas, in one a~a of ~towice, ~fl lead e~ ex~ 19,~ pa~ ~r ~ and near Cz~h~lova~ they ~c~ 5,~ pa~ ~r ~I~ In sevesal areas of CenLraI and Eastern Europe, these sources of exposure have been augmented by high levels of lead in food. For instance, in the smelter town of Pri- brain in the Czech Republic, it was estimated that exclu- sive use of home ~rown fnzits and vegetables would pro- vide 1,042 percent of the acceptable weekly intake of lead for children. A similar problem likely exists in the vdiv-Kuklen-Asenovgrad area of Bulgaria where lead smelting is taking place in the middle of some of the rich- est farmland in the count-ty. Studie~ among adolescents in certain parts of Silesia have shown dietary lead intakes as much as seven times above acceptable weekly intakes for those in the h/ghest decile of intake. POLAND. T~e lnsti~te of Rural Medicine has studied soil contamination across Poland attributable to airborne point sources of metals and the "limLng"~ of acidified soils. There have been dramatic and unfortunate impacts of using indust~al waste to "Lime" addi6ed soils. The metals content of the material used for liming, which came from several large industrial concerns, often exceeded re~:og- ntaed norms, (such as the West German soil cultivation standards for four target metals), by a hundred fold or more. Tl~s is illustrated in the table below. [n major indue- trial areas, it would be difficult to separate the eftects of liming f'~m those of long-term airborne deposition of toxic materials orig/nating from similar point sources. The c~mulative impact of airborne deposition and lim- ing of soils with industrial waste may be seen with refer- ence to heavy metal pol~uHon in allotment gardens near la~e cities. O~ce again, the concentrations of these vari- ous metals can be seen to exceed cultivation standards by 5 to 120 fold. The Institute of Hygiene, the prindpal agew:y looking at me~al contents of food and studying total dietary metal intake among children, has carried out u~efui studies on the dietary intakes of heavy metals. One study has involved tak/ng samples, usually over a 10-day period, of the food prnvided to children living full-time in ip.~titu- Honal surroundin~s. The sample shown in the table below, while not representative of the entire country, shows that in many regions children am ingesting metals at levels far above international norms. Walbrzyskie is particularly stz~,ing in this regard. Samples of crops taken at the farm have often con- rained unacceptable concentrations of heavy metals. Aver- age concentrations of lead and cadmium in potatoes ~rom various places within Katowiee, as well as Walbrzyskie, Kieleckie, and Bydgoskie can exceed WHO ~idelines for lead (see Annex 5, Table AS.I). In the other re~ons, the Table 3.1 Metal content of materials used for limln~ soils in Polznd Me~ab Cont~t f~r~s/x~ milIkm) ~ C~mlum Arscni~ Chromium West German soil cultivation standards 100 3 20 I00 Bol~aw 30,Zf~ ~7~, 1,130 1,984 Mlssteczko 4,563 .. 1,250 t,~00 Orzet Billy 3,700 .... Huts Sendz~mlxa smelting works ...... 13,C00 tad Kur..tt~Id 19~3 BATCo document for Mayo Clinic 27 March 02
Page 33: 39000936
Table 3.2 Allotment gardens near point sources oE met*Is, Poland Near industrial complex- Bo|e~w 12,750 lead Near arterial mad- Bytom 161 cadmium Lublin 158 cadmium Various allotments near industrial complexe~/arterial roads tOO anenic Near leather tannery 3,047 chromium ~ Ma~hwi~ka and Xuch.uski 1983 problems do not seem to be as acute. However, Informa- ['ion on samples taken at the point of exposure do not nec- essarily reflect the dietary experience of the population. Total Exposure and H~alth Outcomes o/Lead in Katol~ice. The best studied environmental health issue in Katowice Prov- ince is lead pollution and its effects on children. This is not surprising because exposure to lead is significant from all major sources. First, consider airborne exposure: data (presented in Annex 6, Table A6.!) show that as recently as 1987, when industrial production in gatowico had not yet begun to de¢line, airborne lead concentrations were so high they would constitute SF~=clal exposuze conditions in North America. A large proportion of the garden plots in Katowlce are adjacent to industrial areas which have been contami- nated both by airborae deposition and the practice of lim- ing the soil with inorganic indush-ial waste. Annex 5, Table A5.2, shows that garden plots in Katowice are heavily con- taminated with lead as well as cadmium. This would serve as one significant source of lead exposure among children. Two extremely dedicated scientists at the local Envl. ronmental Pollution Abatement Center have carried out a Pain-staklng evaluation of the soil quality in virtually every farm and garden plot in the most heavily polluted parts of Katowice. Less than 40 percent of the places that Table 3.3 Daily metal intake from food in Polish adolescent=, they tested were found fit for unrestricted cultivation of edible planes because of heavy me~al contamination. A full 50 percent of farms and gardens were found to be appro- priate only for spedes of edible plants which do not con- ce~t~ate heavy metals, while 10 percent were found suit- able for decorative planes only. Because heavy metals persist in soils, pollutinn abatement will not be sufficient to resolve the problem. This is a major concern since, 70 Pen:ent of the food consumed in Katowice is grown in the province, and 50 percent of the land in the area is used for agriculture. Soft lead levels in the most contaminated residential areas of Katowico are virtually outside the experience of much of the Western world. A standard for lead in resi- dential soft in several jurisdictions is 500 parts per million. Table 3.4 shows that average soil lead levels in three con- taminated areas in gatowice are much higher than accept- able standards. Soft lead levels have been demonstrated to be a princi- pal source of high blood lead in children who are not exposed to lead-based paints. This is because young chil- dren (under the age of S) tend to passively ingest soil by direct contact or contact with house dust contaminated with lead. Thus, in addition to airborne exposure, children in Katowice are potentially exposed to lead both from food and soil. It is no surprise that the blood lead levels among all regions of Katowice are very high among chil. 1983 ~th percentile WHO daily intake maximum 428 57-71 Blalyst~ck 104 305 22 58 l~rakow 431 609 tl! 184 Lubtin 154 411 26 67 Plonk 51 161 81 83 Sieradz 46 17~ 82 246 Slupsk 248 1040 11 49 Walbrzyskie 783 2643 .... Sound. Z~wadr.kt 19~6 Table 3.4 Soll lead levels in three contaminated areas in l~atowice Mean R~m~e Area i 6449 753 - 19,750 Area 2 2124 82 - 6,775 Area 3 1025 447 - 1,550 Seun~:. H~ 1590 BATCo document for Mayo Clinic 27 March 02
Page 34: 39000936
Table 33 Blood lead in children and mothers [n various places within the Katow/ce ~eglon, 1959 Childtm Mothen Szoplencice 26.7 18 21.1 12 Mitj|eczko SI 24..7 17 21.6 15 ZyglJn 26.1 22 20.I 10 Lul~ow|ce 12.7 0 10.6 0 Z~brze 18.9 3 15,9 4 Toszek 17.9 13 13.1 5 By'tom 15.2 10 15.5 Bo~szow 12.3 0 113 0 B~Jn~ 51 ~4 13 17.6 7 Brzo~ce ~.4 8 16.8 .~ H~ t~] (d) dren and mothen except in Lubo~ce and ~ojszow, a~ ~flvely ~ote For ~m~n, t~ Center for ~ Control (C~] the U~t~ S~t~ ~ide~ 10 ~ of lead ~r d~ter of bl~ to ~ ~e ~mum level ~fo~ damage ~. L~eb a~ve ~ ~ ~r d~r ~ for m~i~l ~v~figa~o~ In five of the ~o~ ~t~ in Table 3~, m~n ~d l~eb among the ~dmn w~ at or near t~ ~ I~ and ~ we~ a~ve the t~hold level ~ ~ ~m Katie am ~Ikely ~ ~ combatively b~ s~ce ~v~] c~Id~n with a~te s~ptoms we~ ~ud~ ~m the ~to~ce ~mple. ~ c~d~n had bl~ l~e~ ~n 33 and 87 ~a~ ~r d~fiter. C~ld~n li~ng near the Miast~ko l~d and smeI~er ~ the early 19~ al~ had v~ high bl~ lead l~eb, as a study ~ out by the Arad~y of M~i~ne ~b~e shows. Table 3,6 p~n~ data on bl~ lead I~e~ among th~ ~e ~a~n ~k~ am ~ con~m~ a~ut lead ~ b t~t it ~ aff~ ~teH~al dev~opment, ~ su~t ~t ex~s~ to lead ~ afrOS ~telle~al ~pab~fi~ among ~Id~ in Katowi~. Table 3.7 indi- ~t~ a 13 ~t IQ ~dlent ~ child~n ~ the Hgh~t ~d low~t bl~ lead levels amens c~d~n ~r- fi~pa~g ~ t~ s~dy, ~e ~fid~ s~S ~om lead ~ ~y ~ve ~uc~ p~ throughout ad~t fiv~. The 231 child~ h'om the polluted areas in Katowice also suffer~l from a variety of other sl~icant health problems which may be related to chronic and acute lead exposure: 66 percent were anemic, 33 percen~ had diges- tive t~'act systems, 78 percent had electroencephalogram changes (11 of whom had a history of "epileptic symp- toms% thr~e had peripheral nervous system p~tholog,/, and virtually all had chromosome abnormalltie~ in sam- pies of whRe bto<~l cells. There is some evidence that anemia is a widespread problem throughout Katowice Province, possibly due to exposure to lead. One study shows that fi~m the mid- 1970s to the mid-1980s, the average hamoglobin level among children and mothers in the province was approx- imately 12.5 grams per de<'iliter. This i~ 23 to 3 grams per deciliter below the e×pected level and below the avenge [or Poland. While anemia is a~so,:iated with exposure to lead, it would b~ very difficult to attribute such a wide- spread phenomenon to this single source. Local invesliga- 1ors speculated that anemia might be a result o[interactive effects o[ exposures to several metals and other environ- mental toxins, perhaps mediated through acidification o[ ~oils and loss of blo-availability of nutrients, but in ways which are very poorly understood. HUNGARY. Bl(x~d lead levels among children in cities in Hungary can also be very hlgh.Table 3.8 shows blood lead Table 3.6 Blood lead levels among ch~cL-en/n Zabrze, Katuwice AF Mmn Perc~e > 30 p~Idl I-3 17.3 7 4.-6 20.1 7-10 25.8 21 11-15 19.3 3 ~ H~n I~ (d) Table 3.7 LQ.~ of ~[l~n wi~ d~e~nt bIo~ lead levels, ~to~ce ~ 20 94 I!1 ~ 59 105 2~ ~ 105 BATCo document for Mayo Clinic 27 March 02
Page 35: 39000936
Table 3.8 Blood lead |evels among children/n Hungary A~n Rar~e Perr~nf • 70 I~[dl Budapest: Inner city 24.8 ~.5-57.5 57.1 ' Outskirts 7.6 2.5-20.9 1.7 Romhany 14.0 .. 17.9 Szolnok l&O .. 37,6 levels among dhildren for three localities in Hungary which participated in a study on lead neurotoxtcity coor- dinated by the Wortd Health O~anization. Inner Budap- est and Szolnok were selected because of their large and m~xlemte sizes respectively and their ~elatively heavy traffic flows. The town of Romhany was selected for s~ady because it has a single industrial point source of lead 10ut low traffic flows. la Inner Budapest, where the primary source of lead pollution is from transport sources, the mean airborne lead concentrations actually exceed those of Y, atowlco. For compa~on, the towns of TCaii and South give,ale in Canada with ma~or point sources of lead have airborne lead levels only 8-34 percent of those found in inner Budapest {see Annex 6, Table A6.I). Further evidence of the important role of motor vehicles in ah-~ome lead levels is demonstrated by comparisons of ~'glons of high and low ~raffic flow in Budapest: the range of airborne lead levels runs from 5.4 micrograms per cubic meter in high/low a~eas to a low of 0.4 in a parkland area. T'nat thi.s may have a sign~icant public health impact is illus- trated in Table 3.8. In the inner city, the mean blood lead level is morn than 3 tixnes as high as it is in the outski~. Momver, the propo~on of children with blood lead levels above 20 micrograms per deciliter (a level o~ eq0osure at which one would expect evidence of neu~ol~,havioral lems), is 57.1 percent, compa~,~1 with a proportion of 1.Tpero cent on the outskias, an enormous dLfference. Ahhough the town of Szolnok in Hungary is much smaller than I~udapesto ~dth a population of approxi- mately 70,000, airborne lead levels there can be as high as areas of Katowice. As in Budapest, motor vehicles are the main sources of lead. The study on lead neurotoxicity in Hungary also eval- uated a wide variety of parameters related to nem~behav- total fun~on among paeddpating children. In Romhany, a clear gradient of I.Q. with blood lead level was found: children with blood lead levels above 25 micrograms per deciliter had LQ.s, on average, 10 points below those whose blood leads were less than 10 mi.erograms per deci- liter. However in Szoinok the gradient was only 3.5 I.Q. points, and in Budapest there was no statistically signi~- cant t'~nd at all. At grst glance, this would appear to be contradictory, since the range of blood lead levels in Budapest was higher than in Szoinok which was, in tam, higher than in Romhany. One would expect greater toxic- Ity to be evident in the places with a higher ran~ of blou~ lead. However, as settlements get larger, the degre~ of her- emgenei~ in socio-e~onomic stalin increases. IL-cause this is a powerful predictor of neurohehavioral function, it can easiJy confound the relationship between I.Q. and lead exposure, l,V~le the investigators attempted to ~ake these factors into constdera~on, It is likely that the 8radient in Budapest was obscured by residual confounding effects which were not adequately controlled. CZECH REPUBLIC. The evidence for sibmi.~icant lead. exposures in the area of the Pribram smelter is impressive. Soil lead levels near the smelter can exceed 5J)00 parts ~ million, and even these values may be underestlmates.1 Locally grown food may be a significant source of lead intake for adults and children. Measurements of lead in fruit and vegetables grown near ~e smelter show that a diet made up exclusively of local produce would provide more than ten times the allowable weekly intake of lead, end excessive quantities of cadmium and memay (see Annex 5, Table A5.3). A small battery of three psychome~'ic tests was admin- istered to the study children from the Pribram area. These revealed deficits for both boys and girls for at least one of the three test variables. This result is consistent with other studies of children exposed to lead and supports the valid- ity of the high b]c~d lead values reported f'mm testing in Central Bohemia, rather than lower results from infests done in Belgium. ROMANIA. A World Health Organization study done among children in a Bucharest community adjacent to a lead smelter in 1985-86 showed that among 323 ch~dre~, 184 (57 percent) had blood lead levels between 17-25 micrograms per deciliter and 44 (13 pereen0 had levels between 26-35 micrograms per deciliter. Data available from the WHO study on the relationship between perfor- mance on six neurobehaviorai test batteries and blood lead levels show a strong correlation between increasing blood lead levels and decreasing performance after adjust- ing for age, sex, and parental occupation. The proportion of the variance explained by blood lead level varied from a low of 14.3 percent for a general performance test to a high of 32.1 percent for a test of visua bmotor coordination skills, with those for tests of 1.Q., verbal and unmber skills falling in between. Teachers in the Iscal ~ have indi- cated that children with blood lead leveLs greater than 25 micrograms per deciliter were more likely to have unsta- ble attention, lack of perseverance, and 8rearer impulsive- hess than children with lower blood lead levels. A similar study done with children from the smelter town nf Copea Mica ~ been discussed earlier. BULGARIA. There is evidence of exposme to exce~ive lead in some cities in Bulgaria. One study, conducted from 1986 and 1989, showed that children below kindergarten BATCo document for Mayo Clinic 27 March 02
Page 36: 39000936
exce~ levels o~ lead in ~vod. These children were ingeat- inS between 0,06-0.2.5 mi~grams per day oL lead in diet. hr above the Food L~d Agrtc.~t~re Org~%z~tion (FAO) permissible total dally lead intakes for children of 0.046 mi~gzama per day. The food contained high cuncentra- tiom of lead in all seasom of the year and le~d levels had L'~r~sed over each of yeara of the study, according to the Institute of Gastroentemlogy and Nutrition. Unfortunately, data are not systematica/ly collected from farms and process/ng plants, so we do not know whether the problem with the food supply is a general one or related to specific pmblam sources, [n fact, it was claimed that the resuJts of routine mon/toring food are not re'cained, even in a non-computer-readable form. There has, however, been one study on the lead content of i~tant baby food cereals processed in Romax~'s single factory. ~ fador~ in Svishtov, gels its raw material from all over the coun~v. Of 66 food samples taken between 1986 and 1989, 62 had lead concentrations above the lead standard of 0.I milligram per kilog~n~ Lead concentra- tions in leood samples ranged from 0.08-0.93 milli~am per kllolFam; mo~t samples contained lead in excess of 0.33 mil~gram per kilogram. In the Plovd|v/A~enovgrad area, a principal concern ls lead in soil, since a large lead and zinc smelter is situated in the m/ddle of a valley of prime agricultural land. Land adjacent to the lead and zinc smelter Is cultivated without zones of prote~on or appa~ntly any local or national reg- ulation. Measured lead concentrations in agdcu/tural soil ranged from 12-10~5 parts per mllllon. More than ~6 per- cent of the samples taken in the mid-1980s contained lead above the cultivation standard, after adjmtment for soil acidi~y. Lead levels of seven[ hundred to 1,000 pat°is per milfion in crop growing areas are very high. There is rea- son to believe that food ~-own in the area contains high levels of lead. Annex 5, Table A5.4, shows that crops grown in the ar~a contain lead above the maximum allow- able concentrations. Moreover, atmesphedc conditions in the valley may facilitate the airborne spread of lead-contaminated dust expodn$ settlements in the valley (par~cularly Kukien) to high ambient concen~ations of lead. The average airborne lead level in the Kuklen area in 1989-90 was 2.6 mic~- ~ per cubic mc~'er, which b comparable to the highest levels in Katowice, Poland. Table 3.9 below shows that nearly all the ¢-l~.ildren tested in Kuk/en had blood lead Icy- eis above 10 micrograms per deciliter and the maiority had concentrations above the dangerous level of 25 micro- grams per decil~ter. Indeed, the average bl~ lead level in children in Kulden is 33.~ micrograms per deciliter. No studtea are available which help dis~gul~h the contr/bution.s of ~, raft, h~ d~t, a~ o~ ~ to bl~ lead levds in ~]d~n. ~e ~laHon of aisle I~d i~ ~th ~t~ ~on ~ t~fl ~ead leve~ ~ 1~ ~ld~ and ~o~ance on the W~er Ve~l intelHg~ T~t (~.26, p=.~8). ~is indictor of n~m~o~l dy~ ~on among ¢~Id~ ~ndu~ ~o~g TU the ~O p~t~ol, pmvid~ evld~ce that t~ sus~ ~gh l~d ~su~ may ~ delete~o~ly ~uen~g the development o£~d~ ~ the BALTIC COUNTRIES. Unlike other countries in the region, the Baltic countries have not routinely measmed blood lead. Therefore the lead exposure situation in the Baltic counU'ies must be pieced together from hair lead data, which ~s difficult to interpret, and occasional blood lead sample studies. Annex 5, Table A5.5, shows that the average hair lead levels in the four cities of the indust~al northeast are 2-2.5 times higher than in Tartu. The ordy blood lead survey among children in the northeast, in 5aka, shows an average blood lead level of 105 rnic~c>- gram~ per deciliter. This is not especially high compared with the most polluted Central and Eastern European towr~ and cities. S~RI, average blood lead levels of greater than 10 micrograms per deciliter among children is a con- cern, since this is the level at which neumbehav/oral dam- age might occur. UKRAINE. Konstantinovka b a town with 108,000 inhabitants in Donetsk Oblast, apprexh-nately 50 kilome- ters north of the city of Donetsk, in the eastern part of U~ine. In the center of the town, in a valley that is approximately 70--80 mete~ deep and 6-7 kilometers wide, are located a lead and zinc smelter (with a 180 meter smokestack), a chemical plant, and a metallurgical plant. The smelter accounts for 33 percent ol the air pollutants in the town; the chemical plant, 15 percent; a~l the metallur- gical plant, 15 percent. The lead and zinc smelter, built in 19~0, currently produces about 50,000 me~c ~ons of lead per year despite a shortage of raw materials. Despite its heavy production, no investment for modernization or repair has been made at the smelter for the past 20 years. Staff of the sanitary epldemiology station estimate that about 15,000 people live wit}tin I kilometer of the indup tzta[ zone. Between ~982 and 1991, mean airborne lead levels within one k/lometer of the plant ranged from 2.7 to 5.4 microg~ms per cubic meter and maximum levels reached I0 m~cxog~ms per ct~bic meter, higher than in Katowtce or u.rba.n Budapest. Unfortunately we have no blood lead or Table 3.9" Children's blood lead levels in the area of Plovdiv and A~enovgrad, BuIgarla (yen:~taoots in each < I0 I0.I-I$ 15J-20 20J-25 • 25 Kuklen 1 t t6 20 61 Average of other settlements 3 16 31 25 24 BATCo document for Mayo Clinic 27 March 02
Page 37: 39000936
m,m'ol~havioral da~ on ~pou~d ch~'~ in ~ a~ R~ ~fl l~d ]~e~ m ~ly low ~r th~ ~ ~ndJ~o~, m~g ~to qu~on the me~ of m~ent of l~d ~ ~ ~ough at ~st ~ smdi~ o~l~d ~ ~ ~- d~ ~g near ~int ~u~ ~ ~e ~ ~ or- ~ out, ~ey a~ not of s~enfly ~ ~aii~ to p~ ~de a ~ of cond[~o~ in t~ ~on. ~ey do ~ iden~ ~e s~c ~t ~ of ~a~, ~en by ~on, and they measu~ hit and ~th l~ad ~er ~n bI~ ~ad. ~ile on~ s~dy d~ provide neuter- ion! ~ on ~th ~ld~ aM adult, i~ ~s llmit~ u~ ~s ~u~ it h~s to ~ heal~ outcom~ to ex~ ondi~o~. Respiratory Conditions and Other Problems Assaciat~ with Air Pollution Respiratory disease due to air pollution is the most com- monly reported e~vironmental health problem in Cenl~al and Eastern EUrol~. "this is not surprisL~g because high ambient levels of dust, sulfur dioxide, and other gases are common i~ populated areas of the region. The first of the following three sub-sections p~ovides data on ambient air quality in the region. Th~c.e are presented in non-stan- dardized forms because each data set diffei~l/tom the others In its ortgL~l presentation. The second subsection presenl~ evidenc~ o[ respiratory and developmental pmb- l~ns in specific locations in the region associated with air- borne potlution. The third subsection deals with excess mortality associated with airborne pollution. Ambient Air Quality. Many towns and cities throughout Central and Eastern Europe suffer from high ambient con- cen~'attous of suspended particulate roarer and sulfur dioxide due to the use of high-sulfur coal and fuel oil in pow~ stattor~ and households. POLAND. Marly communities throughout Poland expe- rience high concentrations of sulfur dioxide and sus- pended particulate matter. Table 3.10 below shows sul/ur dioxide concentrations in Polish cities for 1988 in compar- ison with levels in OECD cities for which data were avail- able for various years in the late 1980s. The distribution of means in Poland is much higher than in the OECD cities, with tl~ highest in Poland being more than 10 times that o~ the OECD cities. The problem in Poland is not isolated to a few polluted communities. As Annex 6, Table A6.2 shows, in many Pob lsh communities, sul/m- dioxide levels exceed~l those in the OECD ~ities. In addition, dust concentTations above 100 mi~ograms per cubic meter were common in Potish Table &10 Sni/~r dioxide levela in OECD and Polish citlea r.atowi~e and Kmkow are two o~ the hrge~ industrial centare in Poland. ,According to available data, (Annex Table A6.]), Katowice au~e~/tom very high annual con- cent~a~ions of suspended particulate matte~: in 1987, con- centrations were 3 to 30 times the levels found in cities in Canada, Franc~, the United States, and Sweden in the late 1980s. The da~a also suggest that nitrogen oxide lavels in Katowice are higher than in OECD cities. ~ i.~ surprf.~- in8 because a major source of nitrogen oxide emlsd, ons is motorized tran~po~, which ~s ~elatively undevelop.~d in Central and Eastern Europe compared to the'Vest. On the other hand, sulfur dioxide concentrations appear moder- ate compared with other cities in Poland and ehewhere in Central and Eastern Europe. However, data lot Y~atowice was provided by a d~e~nt agent7 than the one ing dam ~or the rest of Poland, so the values may not be strictly comparable. Krakow is home to numerous en6ssinn sources, includ- ing the huge Nowa Huta Steelworha, an altu~dr~um plant, several ~emical concerns, and :, variety of coal-~d elec- ~city sanerating pla~ts, as well as i~dividual ~d neigh- borhood fmmaces and heat plants. The data show that Krakow has l,~gh concentrations of sulk'm" d|ox~de pav~d with other cities in Poland, b~t not of airborne dust and nitrogen oxides. HUNGARY. In Hungar~ general environmental tion does not appear to be severe enough to be having a significant impact on the health of the popuhtion as a whole. Even during the heating season (when coal bum- ing is at its greatest) sulf'ur dioxide levels rarely exceed an average of 140 micrograms per cubic meier across moni- tored settlements in the va~ous counties of Hungary. As in many areas with traditional smokes~ar.k indus- hies, dust is a major pr~bhm in the rust belt a~ea of sod County. Unfortunately, Hungarians have not system- atically measured suspended dust, but only sedimenting dust. This measure cannot be precisely con'elated with the more common measures of suspended or resphable dust, se we have no way of ~mowing how severe the dust prob- lem is in Hungary compared with other countries. All we can say for certain is that annual average sedimengng dust levels show a four/old variation across the 5 sam- piing areas ta Borsod County in the late 1980~ The dust has been high in eadmJum, copper, zinc, and lead. In recent years, the installation of an electmsta~c participator and changes in the open hearth technology at the steel mill in Mlskolc, along with the economic slowdown, have helped to p~:luce sedimen0.ng dust levels. The ~dushial area of Nag3,teteny of Budapest also has high air pollution. In the area there a~e 8 major industrial ~urces including MetaLlochemia, a source of lead and other 1~eavy metals, sulfur dioxide, carbon monoxide, and OEL-'D cities (late 1980s) 7-56 Poland (1988) 3-636 $~m~. H~ I~ (d) ~10F-~D 1~| (~) BATCo document for Mayo Clinic 27 March 02
Page 38: 39000936
nitn~,en oxides, and the Chinoin chemical plant. During the heating season, the ambient su~r dinxide levels ean re~ch 440 micro~ams per cubic meter. C.~C~ AND SLOVAK R~.~uC~. The ~ of m~ve d~e ~ ~mlova~ health ~e of~k~ d~e ~ the quafi~ of ~e physi~ m~ent. ~e ~ble ~low ~ the ~n~ ~ average a~! s~r dioxide concen~a~om ~ 6 ~o~ of the ~ ~m 1~0 to 1~. In the ~dm~ and ~o~ of no~em ~he~, s~ dio~de leveb morn ~n d~l~ over the l~y~r ~d~. ~ ~ ~e and the ~va ob~sly ~ Bm~lava. ~ ~ble ~ ~t~ ~e d~ ~c dfffe~ ~ ~e ~todc ~nd of ~bi~t • o~de l~e~ ~n C~ ~d OECD ~ dlo~de I~e~ we~ much ~8her w~ da~ w~ ava~ab]e t~n they we~ ~ ~e ind~! ~o~ of ~e Cz~ a~ Slo~ R~bfi~. ~ the ~d I~, t~ d~ncm ~d d~p~a~ and ~ the ~d 1~, ~ din~de levels in the OECD ~fi~ ~d d~p~ to a ~on of th~ ~ ~e C~ ~d Sin~ Re~bfi~ By the 1~, su~ dioxide leve~ ~ m~ I~- fio~ t~ughout ~e Cz~h Repub~c ~S~ ~ 6, Table A6.1 shows ~at a~l av~ge s~- ~ ~o~de I~e~ ~ no~he~ ~he~ were mu~ ~gher ~ ~e 19~ than in O~CD ~m. Mo~v~, ~d~ ex~me ~ve~ian ~n~o~, su~ as ~ on Jan~ 14, 1982, ~1~ dio~de leve~ ~n ~r ~bic m~er ~ Pm~e and ~ am~ of ~em ~he~. BU~.G~. In 1989-90, avenge annual su~ur dioxide levels varied between 28 and 485 micrograms per cubic meier and suspended dust levels varied between I~ and ~0 mlcmgrams per cubic meter in eight communRies in Bulgada with one or more point sou~'es of pollution. The data presented in Annex 6, Table A6.1 show that ambient suUur dioxide and suspended dust levels in Bul~ria are high even in comparison w/th the most p~Iluted areas of northern Bohenda and l~atow/ce. ESTONIA. In general, air quality in Estonia is not as unfavorable to human health as it is in the most heavily lndusMallzed and m'banized areas of Central Europe. Th~ seems to be due to three ~ctora. The cmmtry is not heavily industrialized and nowhere are them large num- beta of highly polluting industries clustered close together. TaLRnn b the largest city and while there are con- cerns about traffic emissions, the city is too small to gener- ate the degree of traffic pollution found in a place like Budapest. Finally, strong winds o/~en blow across north- ern Estorda which help disperse pollution. This process is no doubt assisted by the tall stacks on the two large oil shale fired powe~ plants in northeastern Eaton/a. Data presented in Annex 6, Table A6.1 show that sulfur dioxide levels in Tallinn and Narva are considerably lower than in the most polluted places in Central Europe. How- ever, if the data are accurate, dust concentrations in Narva a~e very high. Narva is home to the l~Itic and Estonia Power Plants, which emit pn:~|~ous quantitiea of sulhu" dioxide and dust. These power plants are the only ones in the world using oil shale as a ~uel, Oil shale is an ineffi- dent ener~/source and ls high in sulfur, but it is mined locally in an extensive network of open pit and under- gronnd operations. Also in the local area is the c/~ of Kohtla-Jarve, where the chemical plant ~antsechim emits large quaniifies of several tox/c substances, including a variety of hydrocar- bons. Slan~sechim relies on oil shale as a feedstock. Nearby is the town of Sillamae, home to chemical and metallurg/cal industries which use radioactive rnatertals such as tantalum oxide, nioblurn oxide, and thorinm as inpu~ There is also rumored to be a ura~um dump site there, but L~ormatlon is not public. It is not surprblng that the Narva-$illamae-Kohtia-Jarve area is considered to be the main area of envirnnmental concern in the country'. The other source of air pollution in the Won is the Eesfi Tsement plant in Kunda, in the re~ion of Laane-V'u-u east of Taliinn. A photograph of the town of Kunda was featured in a National Geographic article on the Ba]tic countries showing houses in the vicinity covered w/th a thick layer of cement dust, like a permanent snow cover. This ~npression ls borne out on visiting the town. ALso unmistakable Is the enormous quantity of dust emerging ~rom the plant's several s~cks. About 13.~ percent of the 7~,0~ tons of dust emitted fTorn the plant per year con- slats of silica (which has toxic effects on the respiratory system beyond simple dust deposition); the dust also con- T~.ble 3.11 Historic changes in average annual sul.~r dioxide concentrations in the Czech and Slovak Republics I970 1975 1980 OECD cities 1511 762 59l 372 Czech dt~e~ Chomutov mS/on 53 ' 7~ 94 126 Most m~ion 57 80 102 132 Teplke reg/on 51 77 93 Ost~va ~'e~o~ ~ ~ ,t~ 55 Prague (]~dov) 100 I~0 128 155 51ovak BATCo document for Mayo Clinic 27 March 02
Page 39: 39000936
talns ipeater than trace amounts of ~e~eral to~c metals, ~uding a~c, lead, ~o~, and ~ It b ~bie ~t no mu~ne or ~I ~ ~ ~ ~s~ for K~a and ~ ~e ~ona] ~i ~on ~ ~ken no ~te~t in hu~n ~alth issu~ a~t~ wi~ dmt ~sions the~. L.%'Ht~ANIA. There are no large areas in lithuania as polluted as the worst areas in Central Europe. However, there are small areas within certain urban areas where ambient contend'attune of pollutants do reach high levels. Annex 6, Table A6.I identifies Kaunas, Slauliai, and Kedai- niai as the dustiest locations in the country.. There are approximately 150 significant industrial emission sources in Kaunas, (about 2,5 percent of Lithua- nia's industry), so it is not surprising that air quality is poor here. About 98,000 people live in areas where aver- age dust levels exceed the daily Soviet maximum allow- able concentration (MAC) of 1.50 microgram~ per cubic meter by 1-4 fold and a further 28,600 live in areas where dnst exceeds the MAC by more than 4 |old. Data regarding benzo(a)pyrene identifies Siaullai as a place with high airborne concentration of th~ known car- cinogen. This is surprising because motor/red ~nsport is relatively light in $iauliai in comparison with VL~nius or Kaunas. ]t is possible that overflights hum the Soviet air base nearby are a significant souse of ambient benzo(a)py- rene in SlsuliaL T~s impression is rei~Jor,.-ed by data showing that ambient concentrations of formaldehyde, carbon monoxide and lead can be elevated in $iauliai. In Ionava, the local fertilizer factory is emitting high levels of a variety of toxic chemicals (see Ar~ex 6, Table A6.3). Of pari'icular interest is hydrogen fluoride, a irritant to the respiratory system. Reductions in respirator/func- tion h~ve been documented among children living near this k~d of fertilizer plant in other locations in Central and E~stern Europe. LATV~. With the exception of nitrogen dioy2de lrom motor vehicles in Riga and fo~aldehyde ~ ~e ~ d~ o~ V~pils, ~ aw no a~as ~ ~Q Mth ~ a~ quali~ pmblem~at least, not of an ~te~i~ w~ would lead to ~o~I ~ce~ a~ut h~n h~lth. Howeve~ there a~ I~] a~ ~th air quali~ ~nce~ of ~ten~] hu~n hea~th si~ifi~n~ t~t a~ not ~fl~ ~ the mu~e moniloHn~ da~. In ~enemi, th~ a~ ~rIy qua~. ~ey inelude: * Liepaja: phenol arising from mil.ita~ sources and benzo(a)pyrene ~Tom motor vehicle traffic. • Olaine: ammonia, phenol, and benzol arising from the pharmaceutical plants and their waste water treat- ment facilities. • Riga: phenol and benzol arising lrom thermal plants, tran~l~rtatiun sources, and other specific point Sources, such as the chemical industry. • Valmlera: phenol arising from local industrial • Ventspiis: benzo~a)pyrene ar~ing from motor vehi- cle and energetic sources. I~LARUS. Annex 6, Table A6.1 gives average ambient air pol]ution levels in the m~lor dties of Belarus. These data show that the principal airborne po[luta.at in Belaros is dtLst. UI<~,I~. The large indu~b-ial cities of Zapomzhye, Makeev]~, Mariupol, and Kons~anti~ovka in the Dcnhass ~'ginn often have high levels of air pollution. The ma~or industrial emitters in rids re,on are metallur~ical plants, coke-chemical plan~s, and underg~und coal mines. Heavy industrial plants are commonly ]oeated within or near to urban residential areas. Efforts to keep people /rum living in so-called "sanitary zones" around these plants have not been successful For example, in Makeevka, approximately 32°000 people live in the "sani- tary zone" that lies with~ 2 k~Iometers of the me~llurgi. cal and two coke-c,hemJca! plants. Systematic measure- merits over many years have documented high levels of hazardous air pol)utants in these residential areas. In Zaporozhye over 10,000 people living within 1 k/lometer of a huge industrial area are exposed to hazardous levels of air pollution (see Annex 6, Table A6.4). Resplratony and D~clopraratal Probbras. This section pro- rides examples of respiratory and developmental sbadies done in several of the countries in Central and F, astera Europe. In the case of respiratory problems, the p~ults described here are consistent with those of well-designed studies done elsewhere. This is less the case for problems described as abnormal physiological development. Devel- opmental problems have not been studied extensively, at least not in relation to environmental etiology. The exam- ples g~ven here are illustrative rather than exhaustive. POLAND. One study as~ociat/ng sulfur dioxide expo- sures with respiratory disease is available which is of sufficient quality to help understand the effects of sus- tained exposure to sul~r dioxide across the country. This study uses information from medtcal examinations for 575.~00 19-year old males being inducted into the army between 1979 and 1982. Since all Polish males were requi~,d to submit to the exam/nation, there should not be significant selection bias in this sample. The inductees were evaluated for chrorfic bronchitis and asthma according to diagnostic criteria which were, unt'ortu- nately, not stated. These examinations took place at 241 centers across the country. The centers were then divided by mean annual ambient suL=ur dioxide levels as measured by the nearest monitoring stations. Since the inductees, as a rule, were evaluated at the cente~ near- est their homes, these served as sun'ogate measures of the sulfur dioxide exposure that the men experienced. Becau.~e of the large number of centers associated with each level of ambient sulbar dioxide, it is hard to imagine that a d/agnostic bias would have applied systematically across all of them. The data revealed that the eba'oni¢ bronchitis rates were more than three times higher in the recruitment center~ in areas of high ambient sulfur diox- lde than in areas of low concentrations. Similarly, the prevalence of asthma was a four times as high in the BATCo document for Mayo Clinic 27 March 02
Page 40: 39000936
worst Polluted areas as In the Ie~t. Unfortunately, no smoking data were provided. Another study, sumnutrized in ~ 7, Table examtne~ the relationship between air pollution and chronic bronchit~ by c~mparing prevalence rates among people Liv~g near Kr~kow v~th prevalence among people living in smaller village& The inves~gators were care~! to divide the sample by m~es and females and to accmmt separately for smokers and nowsmokers. T~e study showed that risks of chrohic bronchitis, using non-smok- ing villagers as a baseline, are higher for villagers who smoke, and for both non-smoking and smoking suburhan- ites, as we would expect. Another investigation compared respiratory function of a sample of children aged 7-]S and non-occupationaLly exposed adults aged 50-88 from the protected zone around the Huta Sendzimiza steel work~ with that of an age comparable sample from the village of Tok~rnia. This study found that mean values of airways resistance in ini~abitants ol the zone were ,S~-100 percent higher than those in inhabitants of Tok~rnla village. Two, higher quality studies have found associations between respiratory health and air query in Krakow. One found relationships between (i) elevated nitrogen oxide levels and increased medical visits for circulatory system diseases; and (ii} elevated concentrations of sospended dust and sulfur dioxide and increased visits for respira- tory complaints. The second, a 13-year longitudinal fol- low-up study of resplcatory function in a sample of Kra- kow residents carried out to Western standards, found an association between air pollution and respiratory funo, tion. Three areas of the city with various levels of su~ate and sulfur transformation ratio (St-R) in the urban air were defined. The study showed that males who lived in the most polluted area had lower F~V1 (forced expiratory volume) levels by about 151 milliliters than did the resi- dents of the other areas, equivalent to the effect of smok- Ing. For females, the pattern was generally the same. In men, the lEVl decline tats, in milliliters per year, over the 13 year period was slgnitic~ntly &star by about 11 mit~te~ per year in the are~ with higher and intermediate STR, which was again equivaJent to the eh~ct of smoking. In females, the prevalence of symptoms was con'ehted the level of sulfur dioxide and d~t in be aiz; however, lung function deterioration was correlated more sU'ongiy with A pathologist ~om the Academy of Medicine in Kra- kow described a study of placentas of 1,000 non-smoking mothers from Krakow, Silesia, and other poLluted areas. Virtually all of the placentas from central Krakow were sub~.~.--t to gross structural changes, which could, in thenr~ have c~nh'/buted to intr, t-uterine growth reta~ation among the ~etusea. Yet, other re~ions with fewer incidents of placental change, had higher infant mortality rate~. If it could be eatablished that the 8ros~ pathological change~ in the placenta correlated with low birth weight, this would be an extremely Lmportant 6riding. Unfortunate|y, noone had the data available to follow this up. HU~AgY, A study carried out under the auspices of the National Institute of Hygiene has found evidence that the air quality in the aluminum smelter town of Ajka has affected the respiratory health of children under age 12. The study uses information on respiratory morbidity among children provided by l~ia~cians in Ajka and the coni'rol community Papa. The average monthly rate reported for upper respiratory diseases, tonslllit~, acute bronchitis, sinusitis, laryngitis and asthma was more than twice as high in Ajka than in Papa for the 2-year period from July 1981 to June 1983. In addition, measurements of pulmonary function indicated that girls bet'~een the ages of 6 and 14 in Ajka were nearly 2.8 times more likely to show evidence of airways o~ttuc~on on spLrometry than in Papa, while boys were 3.6 times more likely to. Mo~- over, monthly variations in the incidence of respiratory morbidity correlated strongly with fluctuations in suh~ur dioxide, soot, fluoride, and dusffalL Interestingly, the cor- relation coefficient was 0.44 for the current month, but, when the exposures were lagged one month, the correla- tion increased to 0.76. in Doro$, there had long been concerr~ about the effects of air pollution from the local power and heat sta- tion and coal mine on the respiratory health of children. When the government: de~ded to put a waste incinerator in Dorog in 1984, it promised to conduct a health study to address these concerns. ]n Hungary, children with asthma and bronchitis r~,~,,ister with the local authorities so they can receive ~ee drugs/or their conditions. This registry is a rich source of data conceroing respiratory morbidity. Using th~s data source, investigators found that among children ages 0 to 14, the prevalence of "registered" chronic diseasef,--primarily respiratory, congenital ~ormaflons, or chronic urinary tract disease,--had increased from 5.8 Pe~:ent to 10.7 percent from 1976 to 1985. Furthermore, the prevalence of asthma was appmxo imately 3 times the national average. The monthly rate of new ca~es of bronchitis and cases of respirstory disease in general were highly correlated with the average ambient sulfur dioxide concentration for the 12-month~ between October 19~6 to September 1987. The correlation coeffi- Table 3.12 Sukr'ur dioxide concen~ations and respiratory disease in Poland, 1979-82 < 10 7 !.18 L59 I~20 37 I.~ 2.55 ~ 6t 1.~ 2.~ ~ ~ 1.92 2,96 ~ 3& 3.~ 4.46 >~ ~ 3.~ 6.~ L i C~ O0 BATCo document for Mayo Clinic 27 March 02
Page 41: 39000936
dent was 0.81 ~or bronchi~ morbidity and 0.78 for t'espt- ratory diseas~ mo~idity. For chlidmn ages 0 to I years, the correla tion coef/~c~ents were 0.92 and 0.83, respectively. ~c~ A~D SLOV^K ~]WUSUC~. Low b~h w~ we~ fo~d to ~ mo~ p~valmt ~ the ~ d~ o~ no,hem ~hm~ than in other ~ o~ the ~ Slovak R~ubll~. Re~ ~uend~ for Us~ ~m, and Tep~ In the m~n~ dis~s of no~he~ ~h~ over the ~ 19B2~6 ~ng~ ~ 7.5 - ~nt o~ live b~, compa~ with 4.3 - 5.5 ~nt for • e non-~ Congenial ano~li~ also ap~a~ with ~ter quen~ in the minin~ than non-~n~ d~t~, ~n 7.~.? ~e~i ~ Tep]ice and ~n ~t ~ Us~ ~n I~2 and I~86, w~e ~ Jablon~, th~ vad~ ~m ~,~,7 ~ent. ~ da~ a~th ve~ ~ and p~bl~a~c. In any ~on, ~e p~po~on ~ c~]d~ ~th ~n~- ~[ ano~li~ b dl~It to ~n~e. ~me ~v~gato~ ~dude o~y ~ous con~e~tal anomali~, w~e oth~ ~dude ~i one, such as st~ b~h ~. ~ cow g~l anomali~ show up at bi~h bu~ othem ~ke mon~ or yea~ to exp~ them~Iv~. ~ addition, d~mnt sida~ ~y ~ info~a~on a~ut ~n~e~l ~ d~e~tl)~ ~g it di~It for ~m ~e~ ~ow how comparable the data a~. For a s~dy ~ no~- ~ ~hemia. we were told t~t ~o~Hon a~u{ ~ outcom~ was obta~ed ~m medi~l ~s at mate~i~ h~pitals and that the d~is of a ~ngeni~l anomaly was ved~ at one year of age. ~ut R ts not clear how t~ was veHfi~ or whether b~ may ~ve a~ • e o~al ~ o(congenltal ano~, R~t evalua~ons by the No,hem ~he~a Re~o~l Health E~s Research Co~a~ra~on ~ve not ~t~ the ~r~er da~, ~ their validi~ ~ma~ ~ d~pute. Table 3.]3 p~en~ data on conge~l anoma~ d~ of UsH had ~m ~n 1972 and 1981. ~e ~ble shows that the propo~on o~ babies ~m with con- genial anomMi~ ~w ~p]dly over the l~year ~. ~s co~nds with a ~ of rapidly ~@ a~ ~u~on in the m~on. Howler, chang~ in paR~ of m~ng con~nital anoma~ must a]~ ~ co~lde~ as a ~sible explanato~ favor. ~e of the mos~ in~g ~n~ of inqu~ ~to the e~ of ~he en~ent on ~d~'s h~Ith ~volv~ the in~uence of attending nature school Once or tw/ce e~ch win~er, children from the mining districts of ~or~hern Bohern~ and cm-tain polluted areas of central Bohemia are sent to areas with better air quality for periods of 3-4 weeks. The influence of these nature ~hool visits on hematolog/c, immune, and respiratory function have been studied using be[ore-eRer designs. Annex 7, Table A7.2, presents results of three di~/erent investigations into changes in he,,-natological ~nct/on of children in northern BohemL~. In all ~ studies, the e~Tth,-ocTte counts increased during the nature school visit. The hemoglobin counts also increased in ~e two studies where R was mea- sured. Monmver, there is ev/dence ti~t the improvements disappeared several weeks or n~onths af/er the children rammed home. Similarly, in Study 3, the proportion of hnmature lymphocy~es dropped dramatically during the time at nature school, only to r~d~nd thereafter. It is pus- sible that these changes have nu~tiona! ~s well as envi- ronmental influences. However, the pattern of w~despread ,,hernia/s one which is also found in the Katow~ce area of Silesia in Poland, where environmental conditions are similar to those found in the mining districts of northern Bohen~a. Thus, R is not uru~.son~b]e to suspect that early childhood exposures to high levels of environmental Pol- lution from multiple sources n~y be havin~ a chronic to)dc e/fect on the blood forming organs. Nature school has also been shown to have a bene~da! e~ect on ch/~dren h~m polluted parts of central Bohemia. ]Figure 3,1 shows improvements in hematologic, putmo- ~ary, and immune function foliow£n~ a stay |n nature school. The data on resplmtory function (|n particular FEVl) are very useful because simiJar data we~ not avail- able ~zom northern Bohemia. Several studies have looked at ~rowth and bone mat- urat~on in northern Bohemia and polluted re~ions o~ the Federal Republic of Germany and the former German Democratic Republic. These studies found that, in the eady 1970s, bone maturation was delayed in 32-54 per- cent of children in the polluted regions o[ each of the three countries. However, by the late 1970s this was no longer true in the Federal Republic of Germany. A descriptive study published in 1986 claimed that in northern Bohemia there had been no improvement between 1974 and 1984. Sever~ studies have found that a variety of chron/c health problem.s, indudinS kidney, lung, allergy, mental Table 3;13 Incidence o~ congenital anomalies, Usti had Labem, 1972 1995 3.2 1973 22136 3.3 1974 2630 4.0 197~ 2347 5.9 1976 2213 7.2 1977 2118 5.8 I~78 207~ zo 19~ ~ 8.2 BATCo document for Mayo Clinic 27 March 02
Page 42: 39000936
| Figure 3.1 F_Jfect of nature school on resplrator~ immune, and hematological parameters among 36 children from polluted parts of central Bohemia Forced Forced F'or~ed Forced VRal ExpL,'ato.-'y Expiratory IVHd-explratory Capacity ml Volume, Volume% I/m Flow Hemoglobin 120 123 2,8OO 1 2 3 Erytrocyty 94 230~ 1 2 3 1 2 3 Immunoglobin Forced Expiratory F~ow l/m l 320 1 2 3 ~gc lsA 120 tO0 8O 12 12 12 ~ 1 = before going to nature school ~ 2 = at the end of the stay f~ 3 = one month after return 5~urce: Bubakava e/aL 1987. CD BATCo document for Mayo Clinic 27 March 02
Page 43: 39000936
Table 3.14 Prevalence of resp/ratory conditions in Devny~ Buls,~'la momin& cough ~0 12 cough: more than 3 monthslye~r 15 6 cough: 3 successive yea~ O 4 ~utum ~ 6 ~putu~ 3 succ~sive ye~ 14 6 wheeze I¢ 6 ch~nlc bmnc~s 8 4 X-ray ch~ns~ "ch~rs~sflc o~ ~ronic b~nchltis" 4 d£~o;'dm and skin diseases are l~ore prevalent among p~.school age children in the n~ning dis~c~s of northern Bohemia than among pre-school ct~d~n In o~er Pore of the Czech Republic. Information from compulsory medi- cal examinations done from 198~-1987, shows a similar pattern among school abe children (with a slightly d~er- ent combination of problems). However, it is not dear how standardized these examinations are, or whether or not physidans in di~erent pacts of the country might be more or less careful to report problems depending upon their expectation of whether or not the children shoed be healthy. These am Lmportant factors to consider when ~ uating routinely coll~ed data such as l~d.s. Nonetheless, these data are useful for genemttn~ a hypothes~ that mnmental conditions in the mining areas of northm-n l~ohe- mia may have affected multiple organ systems in children. One well-clesig-ned study, carried out bei~veen 1982 and 1984, found a relationship between child/l/ness and air pollution in the three Central Boherrda towns of Nera- tovice. Kralupy, and Benesov. In Neratovlce, the environ- mental exposures included dust, sulfur dioxide, hydrogen sulfide, carbon disulfide, ammonia and chlorinated hydrocarbons. In l~ralupy they ~n¢luded dustfall, sulfur dioxide, styrene, ethyl benzene, and acry]onitriJe. Benesov served as the control town. The study was carried out In two parts. Researchers examined appmximatdy 200 school age children in each to~,'n six times over ~ years. In addition, they collected inlrormation on the Ind- dence of pediatric respiratory dLsease in the three study areas using pediatridan's reports. Because all children go to podiatficians for their health care, this can be construed as a population-based data sours. The cumulative inddence of acute respiratory disease among those ages 0 to 15, including pharyngit~, sinusitis, laryngitis, tonsillitis, bronchitis, asthma, flu, and pneumo- nia was higher in Neratovice than Benesov. The d~em~ce was greatest for sinusitis, which v-as 7 times more likely in N~ratuvlce than in Benesov. In IG-alupy, the overall Inci- dence of ~spiratory disease was about 2.4 ~imes higher ~ In Bonesov. The ~p~ were largest for sinusitis and acul~ bronchitis, the latter being 3 limes more fi~uent In Kralupy than Benesov. Bone growth measurements sug- gested that boys in Neratovice were 9.0 months behind boys in the control town while boys in Kralupy were 11.0 months behind. For girls, the delays were 5.6 and 5.9 months, ~spectively. On the other hand, the sample sur- vey did not show statistically slbmLficant trends towards Poorer splrometrlc and hematologic function in the indus- trial towns compm'ed with the control t~wns. IRR~AItIA. Devnya is the site of multiple industrial facilities including a fertilizer plant, a FVC plant, a power plant, and a lac/llty described as a "carbide plant." The range of exposu~s in Devnya is very broad: dust, hydro- gen sul~de, lead, ammonia, hydrogen fluodde, and sulfu- ric acid am all found in elevated levels in the ambient air. The prevalence of flu, chronic bronchitis, a[Jergtc "rash," conjunctivitis, and asthmatic broncl~tis among children and adults were higher in Devnya compared with the con- trol town of Geor&d Tratkov In a prelirr~ study using morbidity surveillance registry data. /n the late 1980s these fred/rigs stimulated a more comprehensive study, which/ncluded a specially designed questionnaire, chest X-rays, and spirometry surveys of 2,3~0 people in Dev'nya and 1,0O0 people in Georg/"IYaikov who were carefully matched for age and smoking status. The study found that chronic bronchitis (and symptoms consistent with bron- chi~) was more prevalent In Devnya (see Table 3.15). The spirometry evafu~tions strongly supported this f~ndinS, which showed that smokers in Devnya had higher pro- PoR/ons of obstructive bronchitis than smokem in the con- tzol town. Similarly, non-smoke~ in Devnya had higher r~tes of obstructive bronchitis than non-smokers in the contn3! town. The big surprise was that non-smokers/n Table 3.15 Pulmonary function among children in Dhnltrov~'ad, Bulgaria ~ Girls Age 11 12 13 14 II 12 13 14 Dtmltrovgrad 2020 2.233 2344 ~ 17~ 19~ ~ ~ Con~In ~ ~ 2967 ~ ~2 2433 ~ 3169 BATCo document for Mayo Clinic 27 March 02
Page 44: 39000936
Table 3.16 Cla~iflcaflon of children's d-velopmenml stah~ in DhnRrovg~ad, Bulgaria ! 2 3 4/5 Dkni~-ovgrad 18 ~' 45 0 leo ControL~ T2 20 8 0 Devnya actually had higher rates of obs~ruetlve bronchiti~ ~ smokers there. The study also showed a correlation I~-ween increasing length of residence in Devnya and increased risk of developing chronic bronchitis. Vratsa is the site of several chem/cal industrles. The air ls polluted with high levels of dust, sulfur dioxide, hydro- gen sulfide, lead, ammonia, and sulfur/c acid. A study has be~n done looking at the dagy vada~don in newly reported cases of seven respiratory, atlergic, or in'Rant diseases in Vratsa in assodation with changes in the levels o# sulfur dioxide, nRr~ oxides, and ammonia (controlling for temparature, hun~dity, and wind speed). The data show sta~I/celly si~dficant correlations between daily varia- tions in the alr Poliutants and variatlons in rates of medi- cal vLs[ts on the same day (range of corrdatlon cne~- den~s: 0~7-0.69), the day aRer {range of con-elation coefficients: 0.30-0.72), and two days after air Pollution epLsodea (range of correlation coe~cients: 0.52-0.68). in general, the correlations are stronger on the same day for acute conditions and stronger over the following two days for asthma and chronic bmnchRts. The town of Dimit~ovgrad in Bulgarla--hesvily Pol- luted by emissions of dust, sulfur diox/de, hydrogen sul- fide, lead, and hydmgan fluoride from fertilizer, cement, and power planls--ls the site of one of the most interest- ing environmental health studies ever done in Bulgar/a. A sample of I00 school children, ages 7 to 14 yearn, were matched with contmis from Harmanly. Pulmonary Rmc- tion studies were carried out on children aged 11 to 14 within that g~oup. The sphometry test, which measures how much air a child can exhale over one second, showed that both males and females had reduced levels of FEVl compared with the controls {Table 3.15). Furthermore, the data show the gap widening with age; by age 14, boys and girls in Dimitrov~rad had approximately' 25 percent less FEW'I than the controls. This widening gap between eapected and actual pulmonary function r~ the con- cern that the effects will b~ long term, especially for those who remain in polluted environments for long Pot/otis of their" life. In adcfition, a clirtical evaluation was done to classib/ children according to theh" developmental stage between ages 7 and 14. F~'y percent of children from Dirni~ovsrad had decreased height, weight, and chest expanslun for their age. Table 3.16 shows that, although no children in Dim,ltrovgrad were in the worst developmental cetegoHes (4/5), only a small n~nor/t'y had totally normal develop- ment (I). Almost ball the children in the study had some form of chronic condition, for which, fortunately, the chil- dren's biolosical reserve provided some compensation. The clinical evaluation also found ~ rates of obstructive bronchitis, chronic tonsiRi~s and laryngeS, and several forms of dental pathology among children from Dhoitmvg~d. An analysis of theh" blood revealed increased white blood cell counts, eosinophlls, and immu- nogloblns, suggesting a chronically stimulated immune system. Overall, this constellation of findings among a young population ls quite disturbing and raises questions about the long term consequences of such a large propor- tion of children being affected one way or another by chronic conditions. ROMANIA. Copsa M~Ica and n~arby Me:leas am homes tu lead smelters whose emissions were made famous by a photo study in National Geograph/c. Problems with lead exposures in these towns have been described earlier. A study comparing of morbidity in Copsa Nfica and Medeas with the control town of Sibiu over the period 1983-87 found that rates of respiratory disease among adults were 1.6-7.0 times higher in Copsa Mica and Medeas than in Sibtu. Among children, bronchiolitis and pnenmonla were more prevalent in the polluted towns. A time series corre- lation of morbidity and air pollution over five years showed a strong correlation (0.64) between variations in ah'borne dust levels and bronchitis among children. A 1990 study of health status of schoolchildren aged 7-12 in CoF~a Mica and Medeas showed that over 63 percent had lower height and/or weight than expected and 30 percent of boys and 48 percent of girL~ had blood pressure above normal. Studies showing reduced pulmonary function in children were de~'ribed earlier. Baia Mare is the second of two lead smelter towns in the vicinity of Cluj with significant community exposures. In one study of ~0 children ages 7-13, approximately 30 pen:ent of both boys and ~iris were found to be below the Rfth percentile for expected height. About 30~0 percent of children had above normal blood pressure. In Turda, a town of 60,000 with a chemical plant and an asbestos cement plant, a 1990 study of respiratory health involving 302 children aged 7-11 showed a prevalence of chronic bronchitis of 11 percent. A spirometry test showed that almost 18 percent of children had forced and peak expiratory capacity of more than 20 percent below normal. The cement plant is likely an important source of work- place exposure: the average time from first employment to a dlag~'.osls of silicosis b 12.5 years (1970-79) among those who develop the disease. A study of cRni¢ ~cords revealed that first medical encounters for asthmatic brun- cldtts were 43 percent more frequent among adults living near the cement plant than in a control community; encounters for chronic upper respiratory complainLs were twice as h~uent; encounters for chronic obstru~ve pul- BATCo document for Mayo Clinic 27 March 02
Page 45: 39000936
reentry disease were 20 pa~'~nt morn frequent, and ~t~ ~or ~n~ de~ snd ~ w~ ~ ~- ~t morn ~uenL ~I c~d~ 7-II yea~ old ~ Ta~v~, wh~ ~ h ~ non-fe~ me~Uu~l pl~t. and a ~I ~ ~tal ~pa~ and ~o~ exp~alo~ flow ~) among c~- ~ a~e ~u~. Howler, ~tho~h 16 ~t of ~e ~- dren ~ Ta~ve~ w~ ~ste~ as ~ ~d an ~i- ~a~ p~valence of wh~ze or sho~ of b~. was ~ to ~ ~e pm~en~ of ~ ~g ~l~dmn 7-ll y~ old who ~d ~v~ ~ ~e ~ 5 y~. ~e s~dy done ~ ~ ~ ~ ~-~ ~- • e ~o~e p~nt. ~e s~dy done ~ Nav~ ho~ ~ a ~N~. ~e~ ~ve ~n ~eral ~ ~mple s~di~ ~ the indus~l a~as of no~heastem ~to~ w~ ~ve p~uc~ ~dings l~ng en~en~l ~u~on ~ • A 2.3-fold increase in the prevalence of chronic bronchitis and asthma among adults in the oi~ shale area compared with those in unpolluted areas. • A 2~-fold increase in allergic sensRizatfon to com- mon allergens among adults in the oil shale area com- pared with those in unpolluted areas. • An increased prevalence of allergic ~ensR4z~tion and allergic dermatitis among children in Narv~/Kohtla- Jarve/$illamae compared with those In Tartu. • A strong correlation between changes in the ~re- quency of medical visits for respiratory disease and tuatlons in air pollution levels in Narva and Kohtla- ]arve. • An increased prevalence of respiratory morbidity and immune system dysfunction in a "clean~ versus a "dirty" part of Kohila-Jarve, One s~udy of 2317 cMIdren aged 3-14 in ~ versus Narva/Kohila-JarvelSillamae, indicated a much higher prevalence of anemia and overstimulated immune sy~ terns among ch~dren in the northeast (see Annex 7, Table A7.4). These findings are quite non-spedflc, and m~y be attr/bu~able to var/ous corabinafions of chemical and mlcroblolo~ical exposures, or nutri~onal ~ctors or both. The most characteristic finding consistent with expoma~ to air pollution is the 7~ fold increase in the prevalence o~ eosinophilia among the d'kiklren from no~lheast F.stonia. A heal~ study was ca~ed out on children In Kelu-a, where a pttlp and ~per ~ contnlutes to ambient ~n- centratlons of ~ dio~de, phenols, formaMehyde, ~.nd hydrogen sulfide, 5 to 9 times the ~iovi~ ~um allow- able concentrations. The study found that ~ l~j~-nt of boy~ and ~S pa~'ent g~rls 5 years old had reduced lung ~apad~y, while 2~ percent of boy~ and 69 percent of gh'ls 6 years old did. LrKRAINE. There is ev/dence of geographic cornda~ion between various ~di~ of m~idi~ and ~ ~u~on ~ ~e ~v~gaflon ~m~ ~e ~dd~ of ~c d~ ~ five d~ ~one~k, Ru~ noye, ~m~u~ ~er~y, and ~) ~ a~ ~n- v~ s~ng. Bmn~! ast~ mo~ldl~ (~ 10,~ ula~on) was ~t~ ~th ~en din~de I~eh (cop ~on c~t = 0.94) w~ch was a~ ~t~ ~th eye ~ mo~idi~ (0.~) and up~ ~p~to~ d~ ~ ~y ~n~U~ smdi~ of air ~u~on and pi~to~ morbidi~ ~ s~eral ~~ ~ ~e, ~thou~ the ~oi~ of ]~fio~ ~ ~ ~ ~iUa~, ~d not ~ on the plac~ ~ to ~ve ~e m~t problem. In ~ia ~st, a m~i~l ~ s~dy was done of ~ml ~iden~ ~g near a ~l ~n~r- ~g p~nt ~i~g fluo~de ~m~un~ ~ dio~de, ~d d~ent ae~h, om~ ~th a ~n~l ~up of ~Iden~ ~m Ya~h~i ~. ~e ~v~figatom ~d ~gher ~o~ p~o~ of c~c bmnc~ (4.5 ~ ~n~ls), bmn~al ~s (4.5 ~), ~ndifio~ (4.0 ~), and pn~mo~ {4.5 ~) As~dy of a~ ~u~on ~ ~fion to ~p~to~ was ~M out ~ L~v. ~gh, m~te and low ~u~on ~n~ we~ de~ acco~ing to ambient leve~ of ~IInt- ~ a~at~ ~th ~a~c (~r~n mono~de, ~c o~de, and pho~dan~). MMi~I c~ ~ ~1~ t~t • e rat~ of ~p~ato~ ~ among c~d~n in the ~gh ~u~on ~ne w~ 1.~1.5 ~ ~ater t~n ~ong d~n ~g ~ the low ~lin~on zoo. ~e gen~l h~Ith ~p~v~ ~th age, but was s~ 1.~2.5 wo~ among ~d~ ~g ~ ~e ~gh ~Bu~on zone, Per~ mo~ ~n~y, one s~dy has ~n out on ~e eff~ of a~ ~Butan~ on ~ld~n's h~l~ ~e ~y ~d~ ~nter of the ~nb~s. Da~ ~r • e study ~me ~m m~l~l c~ ~s of 6~ d~ ~ ~ d~ of the ~ of L~ ~ va~g l~e~ of a~ ~on. Po~u~on w~ ~ther ~d d~yde ~en dio~d~, s~ ~, fo~ldehyde, ~ ~uo~de, and ~n dio~de ex~g the low ~Bu~on ~n~. G~ as~ 5, 7, ~d 9 ~g ~ the mo~ ~ghly ~ut~ d~ ~d ~r physical devel- opm~t, ~ m~ by w~t, height, a~ ~t ~. ~d~n ~der 7 yean ~ abe B~g ~ ~e ~ut~ a~s ~d ~gher ~de~ of ~o~a, aUer- ~c ~o~, ~c up~r ~p~to~ ~ ~ and ~e~. Howler, ~&e~ was ~ mo~ p~al~t ~no~c ~o~ ~y ~ ~n~bu~g to ~r ~ a~ ~n~ a~ut the ~o~p ~ air ~u~n and ~I morbidi~ and mo~ ~ ~ve~l ~o~ of the ~e. ~r ~n~ ~ the ~l~r~ 0 CO BATCo document for Mayo Clinic 27 March 02
Page 46: 39000936
nant wom~n were hospitalized with some form of compli- cation of pre~nancy~ Children born to the¢~ mothers had 4 ~m~ ~t~ mortai~ty in the patna.! period ~ drtn of mothers residing ha le~ polluted regions. A senior *cien~t at a research institute in F, iev has conducted stud- ira on a possible relationship between ambient air pollu- tion and conge,-dtal ano.-nalieS (see Annex 7, Table The data show hi~har rates of spontaneous abortions, con- genital anonmlies detected in the six days altar birth, mul- tiple congenital anomalies, and dorrdnant and X-linked congenital anomalies in the indusidal dries with high air- borne emissions compared with the control town~ ~¢xss Mortalihy. The influence of ~he physical environ- me~t on excess mortality is not easy to evaluate. Unlike lead poisoning, none of the major causes of mortality is uniquely attxibu~able to factors in the physical environ- ment. Therdore. studies linking mortality by specffic cause to variations in pollution levels are unsatisfactory for making causal inferences unl~s they take into consld- eration various li/estyle and social factors. This subse~ion presents evidence not discussed in Chapter 2 of this report on the East-West llfe expectancy gap. POLAND. One study done to international standards examined lung cancer mortality in high and low air pollu- tion dislxicts around I~rakow, using the case control meth- odology. The study demonstrated that, after adjusting for smoking and other confounders, males with lung cancer were 47 percent more Likely than expected to have Lived in a hlgh rather than a low ah" pollution district, and women with lung cancer were 26 percent more likely to have. While the results for men were statkstlcally signi~cant, the results for women were noL This is an interesting outcome because it parallels very closely a study ~n Hamilton, Ontario when~ the size of the env~onmental effe~ was similar. [n Hamilton, as ha Krakow, there is a laq~e steel mli/with a coking facility which en~ts considerable air pollutants. In both cases, the lung carcinogens would likely be among the polycyclic aromatic hydrocarbons {or "polynuclear arematic hydrocarbons" as the Poles call them) coming from the coke oven. A~d in both cases, the odds ratio for females was not statistically significant, because of the comparatively smzll number of female lung HUNGAR~ In Bomod County, the incidence of digestive cancer ks closely associated with nlirate levels in drinking water. The crude inc/dence of a]/dlge~t~ve tract tumors excluding liver cancer (international Classification of Dis- eas~ 150-154) rises from approx/matclX 250 cases per 100,000 population per year in a region with an avenge nitrate concentrat/on of ~0 milligrams per I/let, to cases per I00,000 people in two regions where the nitrate concsntratlons exceed 200 mi~gr~m~ per tatar (~ Flg~re 3.2). While th~ relationship is blolo~ically pisuslble (nitrates rely be converted to careinogerfic compounds in the digestive tract), the study did not control for the age and sex distn'bution of population of the communities, and the results mu~t be considered inconclusive. A study, carried out over the period ~-1~81, com- pared adu/t mortality in Ajka, home of an aluminum smelter, with mortafity in the c~nh-ol town of Papa. Mot- tality from chronic bronchitis, emphy~na, and asthma were higher among men aged 40 to 59 in Ajka than in Papa. In addition, mortality rates for these ¢aus~ wet~ increasing more quickly in Ajka than in Papa for both men and women. Mortality from heart disease (except for men aged ,tO to 59) was higher in all age groups in Ajka than in Papa. Mortality /rein cancer of all causes was higher among men aged 20 to 39 in Ajka. Finally, lung cancer mortality rates for women were increasing faster in Aika than in Papa. Data am also available showing dramatic increases in the numbers of new case* of digestive and respiratory can- cer in four location~ in Borsod County (L~ninvaros, Kazincbarcika, Sajoszentpeter, and Miskoic). In each loca- tion, these increases were greater than six-fold for dige~ tire cancers between 1980 and 1987 and greater than tinx~ /old for resph'atory cancers over the same period. How- ever, the studies did not take into account underlying age distribution of the population. And it is unclear whether the reporting of new cases was consistent over time. Local public health officials tended to attribute th~se increases to long-term accumulation of heavy metals, such as cad- mium and lead, in the environment. However, increased mortality is more likely to be related to substances such as polycyclic aromatic hydrocarbons, chlorinated hydrtx:ar- bona, and nitrate derivatives than to cadmium and lead. Stomach cancer mortality rates have been found to be sig- nificantly above the national average in several rural counties in Hungary and have been associated with the use of nitmsable pesticides and high levels of nitrate in drinking water. One study compared a village with high pesticide use in gzabolcs-Szatmar county to anothar with moderate use. It revealed that mortality rates from stom- ach cancer in the high-use village was 65 percent higher than in the moderate-use village, after taking account of age, nitrates in drinking water, drug consumption, smok- ing and eating habits, and alcohol consumption. The age standardized mortality rate for stomach cancer was 3,2 times the national average in the high pestidde-use vil- lage, and above average in the moderate-use village. There are concerns about cancer mortality in the Nag-yteteny District of Budapest. Between 1979 and 1984, 26 percent of adult male and 23 percent of adult female deatl~ in the Nagyteteny District were attributed to can- cer, compared with 22 percent and 19 percent for Budapest as a whole, after correcting for differences in age disMbu- lion. Three neighborhoods within the Nagyteteny District (Akkugyar, Gyufagyar, and j'atok u. Lakotolop) had par- ticularly high cancer mortality rates especially from gas- trointestinal tract cancer. What is causing this high rate of 8astrointestin:.l tract cancer is not clear. This type of can- cer is not usually associated with airborne industziai emi~ siena (though it might be related tu passive ingestion of contaminated soil). One hypothesis is that oil wastes stirred up from the bottom of the Danube River has con- BATCo document for Mayo Clinic 27 March 02
Page 47: 39000936
Figure 3.2 Incidence of digestive tract cancers in relation to nit, ate in drinking water in seven areas of Borsod County, Hungary Lnddence per 100,000 Avmge and n~x~num nim, te concenbates 500 400 300 200 100 120 140 1~:~ 180 200 I 425 515 { 52~ ~ Both ~1 Males F"I Females 1-7 ~ Areas ia Borsod County Sou~ Hert~man 1990 laminated local bank-filled wells. At present, the available data do not allow any definitive conclusions about the impact of environmental pollution on the health of adults in Nagyteteny District. BALTIC COUNTRIES. One study compares "proportional monality" in the village of Saka, (2--4 kilometers ~rom Kohila-Jarve), over the period 1979-88 with the rest of Estonia for 1980. Table 3.17 pr~--~ents a version or'that da~a, which has been corrected to take into account the differ- ence in the all-cause mortality between Saka anti Estonia as a whole, The six-fold inc~ase in respiratory mortaBty is very large and cannot be explained away by difference~ between the age structure of the local population and Estonia as a whole. The local air quality is not as lx~r as in many other pans of Centra] and Eastern Europe where similar statistical evaluations have not been done. It is ]~sslble that respiratory mortality is due to .~moking or occupational exposure. However, if exposure to environ- men~al pollution is the primary c~use, this might mean lhat environmental contamination has had a larger impact on mortality than we estimated in the determinan~s of health chapter (Chapter 2) or'this report. Table ~A7 Mortality in Saka compaz~d with E~tonia a~ a whole, 1979-~ Cardlovisc~lar 45 37 Cancer 7 9 0.~ IncH,, ~i~nings, Holence B 7 1.14 R~pirato~ 12 2 6.~s Other cau~ I 5 0~ 35 0 CO O0 4~ BATCo document for Mayo Clinic 27 March 02
Page 48: 39000936
Table 3.18 Districts with concordant high male-femalt site specific c~nc~ rates, Bul~'ia, 198..e-87 Plovdlv 13.1 S~tla city Gab~ve 12.7 Gabr~vo Ruse 12.3 Pemik Pemik 11.7 Si[~ra 10.8 V. ~ovo I0~ V. Tu~ovo Va~ 9,6 11.5 11.2 11.0 8.9 8.6 8.6 7.4 2.4 2,3 2.2 2.1 i.9 1.6 1.6 S~urr~. He~s~n 1991 Another study looked at the association of lung cancer with smoking habits and residence in ~ol]uted communi- ties. After ad~.tedng for age and smoking habit, the risk associated with residential exl~ure to pollution was 1.5 (95 percent confidence interval=L04--2.3)o which suggest~ that those living in polluted communities have a 50 per- cent greater r/sk of developing lung cancer than those llv- ing in environments considered #clean." Kedainiai has received a lot of attention over the years because, during the 1970s, sulfur diox/de ern~ions from the fertilizer plant destroyed the local forests. The inddence of lung cancer in Kedainiai was the highest in the country between 1970-79. Furtherrnom, the ratio of affected males to females, about 8 ~o I in the rest of the country, was much lower in Kedain/ai, suggesting the influence of a common risk factor such as the airborne contaminants. As of 1988- 90, the lung cancer incidence rate in seven conHguous dLg- triers around Kedairdai remained the highest in the country. BULGARIA. Using data supplied by the National Oncol- ogy Center for 1985-87, we have ana|y~ed the age stan- dardized cancer incklence rates looking for concordance between districts with high male and female rates. Table 3.18 presents data for colon cancer and for myeloid leuke- reia, for which there is considerable male-female concor- dance across districts. For colon cancer, 5 of the 7 d/stricts with highest incidence rates are found in common between males and females: Plovdiv, Gabmvoo Ruse, Perrdk, and V. Tumovo. For myeloid leukera/a, all 7 of the districts with highest Incidence rates among females are represented in the top 8 among males. This high level of concordance does deserve careful follow-up because can- cers originating in the bone marrow can be caused by exposure to ionizing radiation and to benzene. Given the secrecy in Bulgar/a regarding sources of and exposure~ to ion/zing radiation and volatile organ/cs, this remains an iml~rtant outstanding concern. Contaminants/n soil, water, and food may cause stom- ach and colon cancer, so these diseases deserve special consideration in any survey of environmental health. However, environmental influences on stomach and colon cancer have not been well documented in epidemiologlc studies in other parts of the world. Nonetheless the con- cordance of regions with high colon cancer rate between males and females deserves further attention. Plovdiv, a district with several industrial sources of soil and food pollution, appears to have high incidence rates for stom- ach cancer as well as for colon cancer for males and females. Gabrovo and V. Turnovo are also represented as areas of high stomach and colon cancer. Of course dietary and other factors may be influencing the prevalence of these cancers in these areas rather than environmental conditions. Further investigation of these relationships id needed. Lung cancer is perhaps the most important cancer of environmental concern and, fortunatel~ is the cancer for wKich the most data are available. Data from the early 198~s, show that the districts with high lung cancer inci- dence rates were also tho~e with industHa| facilities, including areas with the greatest problems of air pollution and occupaHonal exposures. In addition, the oil refining district of Burgas is represented as an area of high lung cancer incidence rate. [t should be noted however, that there is little correspondence between the districts with a high rate of lung cancer for men and for women, suggest- ing occupational rather than environmental exposure may be imporlant. A separate analysis of the 20 settlements with the highest age standardized lung cancer incidence rates between 1971 and 1980 shows that many are places with ma~or industries. For instance, Pomofie, SozopoL and Nesebar all cluster around Burgas. There is also a close geographic correspondence between reany of the areas of sell pollution in southern Bulgaria and areas of high lung cancer inddence. This does not suggest, by any BATCo document for Mayo Clinic 27 March 02
Page 49: 39000936
Box ;3.1 Chernobyl There b wlde~pread apFn'ehenslon among populations ~ to red|o~ct/ve/a/lout hum Checnobyl about the increa~.d rbk cl cancer which z~ght r~sult h'om radLttlon. Yet, based on the current belt ev~ence, s.,~y' increase ~n cancer deaths ~ alm~t test, airily be ep/de- a.~ol0E,,ically undetectable against the nornud high back~ound level of fatal cancer {about 20% of all deaths), and wl]] in most ca~es not show up for at |e~-st ~another I0 years. The foLtowlnS t~b]e shows the px~dicted h'equency of radlation-lnduced cancer ~rom ¢xl~n~l ~i- albn, relative to normal cancer fl'ec~uency, by' distance of re~idance from ChernobyL It can be ~ th~,t for those who were evacuated qulck~y--the r~ident~ of Prlpyat for eaample--the average do~e of whole-body gamma radiation was ;3 Rein, which would be e~timated to cau.~ approximately 68 exb-a cance~ during be ~fedme ol the 4.%000 inhabltant~. The rbk can be seen to be hasher for those who lived between :3 and l$ ki}ome_tm horn Cherno~l sL'~ce they were not evacuated as quicldy, and may increase their l~'etkne canc~" rb]c by more than I0%. However, even thi~ level of xLdc is unSkely to become detectable through epidem~ologlcal stud|ca. Predicted Normal Cancers In Reaidenb of Evacuated Zone, [~lus Extra ~'rom F..~ter~] Radiation ?r~ay ~3 kin1 4S 9,00~ :3 68 9,0~3 ~77 I,~ ~ 1~ I~ 1.14 T-IO 9 1~ ~ ~ ~ 1.12 I~ ll.fi ~ 5 ~ ~ 1.01 ~ 14.9 ~9~ 5 37 3~17 1.~ To~l (~ ~) I~.9 2~,~ 12 ~ ~ ~n's ~id Stands ~m ~t~mally~ml~S 1131 we~ not ~on dung the fi~t days and w~ after t~ a~d~t. ~is ~m ~s given ~ to ¢ontrove~y. ~e s~y show~ an ~c~ in th~Id ~ ~ence, s~$ ~ l~, ~ ~ m~u~fl~ sd~nt to the ~'a~atlon zone and ~ ~ ~ometen oI the p~nL ~ s~dy w~ b~ u~n ve~ $~H n~n ~ than I0 ~) and the~ b concern that the in~ ~y be an a~a~ ba~ on ~ su~e~a~e a~er ~e a~dent. ~e fo~o~S da~ show ~e ~ of ~d~ce of c~dh~ th~id ~r ~ ~ ~o~ (198~) ~d a~er the ~mobyl d~ster (1987-91). incidence of Thyroid Cancer in Children Up to 1~ Years of Age 1985 ]9~6 1987 19B~ ]999 ~990 2~2 I| Ihe~e data ass vaUd (Le. ff th~ i~ not a~butable to a ~ive ~ ~d~ effort), ~ show a huge ln~l~ ~ ~e ~dd~ce of • ~id ca~er amon~ ~[~d~n ~ the R~on o~ Gomel w~ ~ ths h~vi~t ~d~ve/aUout. ft has ~ c~ thsl thee clncen sp~ ~pldly to ~e lun~ ~ ~usual ph~omenon, and do ~ ~ well ~ ~dltlonal ~s~ent. It b ~t~g to note t~t ~ Incase ~ ~t~ four yean of the d~ter, s s~ ~t~t ~ by the s~nda~s of ~t ~nce~, ~t ~t ~pbu~ible ~or ~ld ~c~ ~ ch~d~n. ~ tbe o~er ~nd, a s~ ~or ~id n~ui~ ~ a ~mple o~ I~ ~ple fi~S ~und ~emo~], end ~n~s, did nol Rve~ an elevat~ ~ddence o~ n~ul~ ~ t~ ~a~y ~ pup. ~ ~]s~, ~e ~em t~t ~ ~y ~ an ~ide~c of th~id cancer ~ ~iJdmn develop~s as s ~ult of fa~ut ~m ~em~yi o~ot ~ R~ at ~ t~e. Anoth~ ~ ~cem b that ~e ~lafion has mult~ ~ ~s~ ~h de~. Yet the~ a~ ~v~l se~ of s~tls~ which do not sup~ ex~ ~eR to ~ • bl~s to~xd over-~S ~fier ~e a~d~t. ~e fa~ ~t ~ w~ n~ ~n b ~m~ negs~ve e~den~ ~ i~. Mo~v~,~ R~finS ~uen~ of con~e~l ma~o~fio~ to ~I ~u~ to ~d~don'~m ~9~ to 19~ do ~t ~ea[ a d~ ~ ~edienL S~[ar[); ~eR b no ~on ~Rn b~ de~ ~en~ by R~n o~ ~e ~un~ a~ ~e average ~d~tlon d~by F~a~)~ th~ b a~t~ ~ the eff~ o~ Chemobyl, d~pite ov~he~g ~d~ ~m p~ous ~ ~at ~ncer b the only la~ eff~ of ndi- a~on. A sffid health ~n ~nta~st~ ve~ u~n~t~ co~ ~ ~e, Russia, ~d ~la~s. Ho~r, ~ s~y ~ound s high level o( 37 0 OO BATCo document for Mayo Clinic 27 March 02
Page 50: 39000936
w.es~, tl~t ~oll pollution is a risk factor ~or lung cancer. It simply ~ the n~ ~or sys~ ~l~on m~ple ~ ~d h~l~ outcom~ in ~ve~l ~o~ of ~e c~n~. ~ ~ SLOV~ ~P~. ~p 3.1 dep~ the ~ of ~e Cz~h and Slovak Repub~ sge of ~ide~ who ~ve ~ s~s wi~ ~e wont a~ ~u~on leve~ ~e band of d~ along no~w~t ~ o~ the C~ and Slovak ap~ to ~ a hea~y ~llut~ a~a whe~ {he of ~iden~ a~ ~ to high l~e~ o~a~ ~u~on. ~p3.2 p~n~ ~e ~an~ for f~l~ by d~ (~le ~n~ by d~ ~ s~r). ~e ~o~ ~{h low~t ~le l~x~nd~ ~ude ~ny ~e d~ ~ no, hem and w~tem ~h~ ~ h~y ~Hut~. How~e~ the pi~ ~ not ~out ~t~d~. Ce~ a~ in the Slo~k Re~ ~ve low ~e ~n~ d~pite ~e~ ~Hvely qu~. ~ con~@, ~t ~he~a wo~ ap~r to ~ a ~oa of ~[a~vely ~vo~able life ex~a~ d~pite ~r a~ qua~. The contraction of environmenlal and social factors nowhe~ morn d~t ~ ~ndle a~lyfi~H~ and nowh~ mo~ ~nt ~ ~ no~ ~h~a. ~e d~ of no~ ~he~ ~ hea~y ~nt~ amon~ ~ ~th the ~h~t ~u~c momli~ ~tm ~ the ~h Re~bllc ~ d~ not apply mealy to I~ ~nc~and ~iov~r mo~ ~t a~ to p~ lems such ~ e~dd~ ~d acridlY. ~ 33 ~mpa~ the ~ ~d ~o~-~ d~ ~ mo~i~ m,~ ~or ~ch ~x for aH caum and all ~n- c~ Mo~a~W m~ w~ ~is1~tly higher ~n the ~ ~ ~ ~ ~e ~on-m~s d~ ov~ five ~,ve yea~, ~l~ of ase and ~x, strong evi- dence of a non-random e~. ~ the da~ non-~o~y d~but~ in a way whi~ ~ght ~ ~tent ~th envi~nmen~a[ influ~c~? Table 3.19 ~v~ standa~ indden~ ratios (SI~) for colon, and stoma~ ~ncer. (~e SIR ~or the Cz~h Repu~ ~c as a whole B I~, ~ t~t a value of I~ would ~ inter- p~l~ as ~ ~nt mo~ t~n ~ ba~ on the age dB~bution o[ the ~p~a~on alone.) ~e inddence rate ~or aH th~ ~nce~ ~ higher ~ the m~n[ng distd~s Map 3.I Districts of the fo.rmer Czechodov~da by the percentage of resldent~ living in are~s wi~ the ~ghest levels of a~r pollution ,,10.0 I0.0~25,0 25.0.~,0 45,0-75,0 ~,?$.0 BATCo document for Mayo Clinic 27 March 02
Page 51: 39000936
Map &2 F~ale llfe expectancy by dlstrl~t, 1~1-.~ ~73.0 73.00. 73.50- 73.75. 73.~0 73.75 74.~ 74.25 74.~ ?,t.7S 75.{~ 75,~0 in the counh3, as a whole. However the SIRs for stomach and colon ~ancer~, which are not known to be a~odated w~h air qua~/~, deviate touch Ie~s f-ram the expected than does lung cancer. F-vidence of potential exposures to carcinogens in the mining districts ts not hard to find. Concentrations of up to 800 nanograros per cubic rooter of three carcinogenic polycycli¢ aroroatic hydrocarbons (PAID were found in dust samples in the vicinity of TepIice in 1988. High con- centrations of pollutants have also been found in rain- water in Tepllce (see Annex 6, Table A6.7). For exarople, polycyc]ic aroroatic hydrocarbons were found in roea- surable quantities tn 60 percent of the rainwater saro- ple~ collected. It would not be unreasonable to assume TabLe 3.19 Standardized incidence ratios for cancer in the that high levels of pollutants are found in vary/rig degrees in roany other local areas within the mining distr/cts. The adult mortality and cancer inddence data should be interpreted in light of the ev/dence preeented earlie~ that infant mortality in the m/n/rig d/sirlcts was also ele- vated and tl~t .~3dal factom could not explain away the ai~ pollution gradient of i~ant roortaEt~ Together, the~e observations surest that poor health which be8~ at or before birth in the m/r~ng district~ of northern Bohemia continues throughout ~e. if fac*or~ in the chemical envi- ronment are respor~ible for theee patterns, the roechanism might be either a latent effect, wherein cance~ and other chronic d/sea~ expre~ themselves after long-term ~ Czech Republic L~/sl~ays I~.8 113.9 IS3.2 93.4 Colon 113.8 95~ I~3 ~.3 ~omach 11Z7 94.0 117.4 ~.3 0 BATCo document for Mayo Clinic 27 March 02
Page 52: 39000936
Figure 3~3 Mortality by Mining and Non-Mining Districts of Northern Bohemia, 1983-87 All Causes All Cancers St~a~lized mortality ratio % Standardized mortality ratio % 150 150 loo 100 1983 1984 1985 1986 1987 Females 1983 1984 1985 1986 1987 All Causes All Cancers Standardized mortaLity ratio % 5ta~dardfzed mortality ratio % 150 150 100 0 1983 1984 1985 1986 1987 100 [] ~g d~c~: u,~ L, Teplice, Most, Chomutov, Deci~ t No~-rnir~g dts~cts: Louny, Litomerice, Lt"oem:, Jablonec, Ceska L~p 1983 1984 1985 1986 1987 BATCo document for Mayo Clinic 27 March 02
Page 53: 39000936
sm'es to spec~c chemicals or a long-term s~luehe of ch.mrdc toxidt7 d~ng ~e genenI en~m~en~l con~o~ ~ ~I ~hemla a~ ]~s ~e ~n in no,hem ~hem~, a~ s~ng co~e~tio~ ~ c~ h~l~ s~ ~ and the quali~ of ~e enact ~ whi~ ~ple live. For instate, the sta~l coition b s~ng ~een the p~on of ~fanb ~m a~U for g~- ~anal age, by dis~, wi~ lhe pm~on ~ ~ple liv~g in a~as ra{~ as having ~r env~enml quali~. one analysis, ~ ~nt of ~he va~n~ ~ "s~ll lot ~- ~onal age" was statlsti~lly exp~ by en~mnmental qualit)~ Age s~andard~ed all~au~ mo~a~ ~ lal~ with envlronmenlal quali~ to a si~r d~ Central ~hemla is a m~on wi~ mu~ l~er dlvo~ rat~ and ~ much s~l[er ~psy ~pu~on ~n ~h~ia, ~o ~emo~ap~c ~om that m]al~ {o ~r health s~. To ~d~nd t~ lhese ~l~demograp~c fa~o~ on h~I~, we m~t~ ~e distd~ In le~s of env~en~l q~ ~h divo~e m leg and pmpo~io~ of ~i~ and ~I~t~ ~ la~ions, as follo~ * S~ll for g~tio~l age wi~ ~nta~e ~ ~0.76, ~.~ *Smal] for ges~ion a~e with divo~e rate: ~0.84, p=.~l * S~ndardlzed mo~ality ~Ho wi~ ~rcen~ge 8~si~: r=.41, p=.18 * Standard~ed morality ra~io ~tb divo~e ~.51, p=.~. ~e r~ul[s suggest that th~ ~al vadab]~ stronger co~lat~ of "s~ll for g~m~o~l age" ~ c~l ~hemia ~han envi~ental quali~ but weber ~ates of the sta~dard~ed mo~aH~ m~o. U~o~t~y, the data do not allow us ~ ~te a mul~-vadab]e ~e] to test ~hether or not the~ a~ inde~ndent ~at and e~vimnmen~l Me~o~lobinem~ ~d Ni~r~ i~ Dri~in~ Wot~. Ni~at~ ~ ~Hnk[ng water or b~ast ~ ~n ~u~ me~hem~l~ binemia or '~lue ba~ syndrome," a ~t~a~e~n8 ~n- difion. M~hemoglobinemia is s fo~ of ch~i~l ~ph~- laHon whe~in the oxygen-~g ~on of is b}~k~ by meta~lit~ o~ nl~ate which bind to h~ gJobin in the r~ bl~ cel~. ~e~ is eviden~ of mo~ as~at~ with high levels of nixies in d~ng ~ter in Central and Eastern Eum~. HUNGARY. From 197~1982. there w~ I~3 cas~ of methemogloblnemia in Hunga~, ~dud~g deaths. ~e a~ o~ s~al concern ~ ~ Count. ~e average ~ncentrat/on o[ ~t~tes ~ water ~ County ranges from a low o~ app~tely ~ ~ ~r liter to a high of ~ater t~n ~0 ~li~ ~ ~ter. ~'els a~ve 45 millig~ per liter a~ ~ide~ ~ten- ~all}' dange~us to health. ~e~ ~ eHden~ o[ a ~on- s~p ~n the ~dence ~te of methem~lob~ various xegions within Bo~s~xl Counp/and *he average nilrate ~on ~ I~l ~t~supp~ In ~e 1~, ~e ~famH~ rote ~r ~ d~ in Coun~ a~ was 3.2 ~ent. ~e humor of m~ ~ ~m 10 ~ I~ ~ ~ ~ 1978, ~e ~ak yea~ In 198~ a p~m was i~t~ ~ dilute nitmle l~e~ and, ~m ~ntly, to ~pply ~ ~ d~g water to ~an~ S~ ~t ~e aB ~an~ in a~as wilh ni~t~ ~nta~t~ dfin~ng water ~ve ~n supp]i~ with ~o Hte~ ~r day o~ ~l~ water in ~ly~hylene ~. ~ ~ ~ult~ ~ a d~li~ o~methem~lobinemia ~ I to 3 ~s~ ~r year. Pot~[~l ~urc~ of the high ~t~ ~clude f~er mno~, o~a~c waste sp~ad on ~i~, d~si~om of a~me ~en o~d~, leachai~ d~g wat~ ~, ~d e~ions ~m ~emi~l ~VAK ~P~C. M~hem~lob~em~ has ~n a p~lem in ~ny a~ of the ~ovak Re~b[ic. 1~I a~ 1~, the~ we~ ~5 m~gl~ia ca~s ~H~ ~ ~he ~ovak Republic, ~cluding 12 death. one d~. Au~od~ a~ ~e ap~nt d~line meth~l~e~ ~ a ~bHc ~u~on p~ram to ~an~. P~td~ and o~t~a~ and the [~al hy~ene s~om ~ve ~ ~m~g ~ the p~am by supply~8 ~o~on and a~l~ng ~me water su~ pli~ ~ of c~. B~GA~A. ~ of the 28 ~o~ of th~ c~n~--Tur- go,re, S~m ~gora, and Buckeye Mgh leve~ ~at~ ~ d~n~ water. Ten y~r-ave~ge nitrate ~n- ~n~o~ we~ 70 to I~ ~ ~r ~ter, with ex~r- sio~ ~ ~ as 2~ ~a~ ~r ~ter (the Bul~a~an s~nda~ ~ ~ ~a~ ~r Hter). In s~ other ~on~ P~k, Ku~ly, Yam~L S~ven, Va~, and ~ulc~he l~year av~a~ leve~ we~ ~ to ~ milli- ~ ~r Hter. Morn ~n ~ ~t of the dis~s in ~e ~o~ ~ve l~ a~ve ~e grandam. In all nine ~om, ~e ~n~l ~ ~r ~te ~n~n~o~ upwa~. In ~e ~er ~ ~o~, 70 ~t to ~ ~r- ~nt of the ~fion b ~ ~ dfin~ng water con- ~ng ~a~ a~ve ~e s~a~. In [he six other ~om, (as well as ~o o~e~), ~5 ~ent of the ~ ple a~ ~ to ]eve~ a~ve ~e ~ffate grandam. F~Hy, ~ eight other ~o~ o( ~e ~un~, 2~ ~ent of the ~lation have ~ive ~te ~n~fio~ • e~ d~g water. U~o~ately, the~ ~ vow H~le da~ avallable on the ~dd~ce of methemogl~em~. ~bHc of~Is ~d con- ~dl~o~ a~ of ~e ~dden~ of ~e d~s~ • e~o~, ~e~ was ~ment a~ut whether or not ~HI~ water was ~in~ ~pp[i~ to p~n{ women and n~ ~ a~s ~ ~n~t~ d~g ~ter. ~e o~I ~im~ ~t ~u~ water was ~g pm~d~, but we ~uld ~d no ~aflon of ~. ~eraU, we found ~e h~ o[ ~ of m~ob~e~ quite s~r- ~g. ~ ~ ~, ~ ~mp~n ~o H~gaw, ~ate 41 BATCo document for Mayo Clinic 27 March 02
Page 54: 39000936
pollu~on is much more widespread and the public hemlth measure~ used to protect against it are much morn limited. Public health o~ci~ls dL~'ee about ~e souses of nitrate pollution. Although it is commonly thought that the nitrate [~]lut/on is primarily due to over-fert/lizntion, one 20-year t'er~izat/on experiment in gtara Zagora found no co.-xel~on be~een nitrate [e~IL-.ation and ground wat~ nitrate levels in an area where the ground water nitrates ranged between 12~ and 240 mli~grems per liter. However, the investigators did find a correlation between fertilizallun and ~-ound water nitrate levels in areas with ~andy soils. LrrI~ANIA. There are high levels of nitrates in drink- inS water in many parts of Lithuania, ranging up to 200 milligrams l~r liter. However there is very little data on eithex the sources or health impacts of the nitratee. While the primary sources of contamination a~ thought to I~ fertilizers and industry, tMs has not been subjected to crlt- icai investigation. There have been sporadic cases of meth- emoglobinemia dLagaosed among newborm each year. Officials suggested that I to 3 cases were being found each year, that the situation had been "worse in the past," and that the condition was likely under-diagnosed. However, each of these assertions was based on hearsay and there did not seem to be any systematic reporting of methamo- globinemia in Lithuania. Approximately one-third of Lithuania is covered by a program (ff water replacement for pregnant women. The local hygiene centers and medial clinics test the drinking water being u.~ed by newly pre~ant patients and provide replacement drinking water during pr~nanc), where nec- essar~ This program is quite unlike the one in Hungary which provides water to newborns and children, rather than to pregnant women. The difference in emphasis likely reflects a difference in the understanding of the eti- ology of methemogiobinemia, but does not seem to have been the subject of an), discussion or comensus-bullding among public health officials in Central and Eastern Europe. ROMANIA. Elevated nitrate levels are fotmd in local water supplies in all but 2 of the 41 districts of the country. A 1990 survey of water supplies in 2,474 rural Iocattom around the country showed that 7.1 percent lind ~itrate [evels above 200 milligrams per liter, I0,1 percent had between 100 and 200 milligrams per liter, ami a htrther 19.1 percent had between 45 and 100 milligrams per liter. In 14 districts, (Mehedinfi, Dol~, Olt, Telcorman, Calarasl, Con~tanta and Bucure~ti-~AT in the South; Tulcea, Braiia, GaIati, and Vaslui in the East: Botosani and gnceava in the northeast;, and Satu Mare in the northwest) more than half of the water supplies had nitre te levels above the standard of 45 milligrams per liter. In these dLst'dct~, up to 13 per- cent of the newborns were reported to develop methemo- globinem/a annually: However reporting of deaths due to the disease is very incomplete around the country. Some insights into the health impacts of ingesting nitrate-pol- luted water may be gained from a special study of chil- dren in high nitrate areas in the Mehedinfi/Dolj area. In 1989, 55 percent of the children in the study area had ele- vated methemoglobin in their blood. In 1991, there were 181 cases of metbemogIobinemia, including 35 which were associated with diarrhea. In total, there were 9 deaths, for a case-fatality rate of 5 pe~ent. Th/s is a much higher rate than would be implied by routine reporting, since only I to 2 deaths from methemogloblnaraia per year were routinely reported from Mehedinfi and D~Ij in the 2 years preceding the study. A.case-[atality rate of 5 Percent would potentially make a sl~iticant contribution to infant mortality in any district where methemoglobinemia was a common problem. 8~LARt~. Nitrates in drinking water would appear to be a serious problem in parts of every oblast in ~elarus, especially where shallow wells are used. Table 3.20 shows the ma~mum measured nitrate levels by oblagt, between 1987 and 1990. It is not clear what proportion of wells in each oblast has nitrate levels above the max/mum permi.~ible level of 45 rnilli~xams per liter. In Brest Oblast, where the highest levels are found, approximately 50 pen:ent of samples e×cced this level Despite high nitrate levels, no cases of metbemoglobinemia have been offidally repo~ted in Belsrus. This is hard to understand given the experience of other countries in the region. Other Environmental Health Problems in the Region In addition to the five groups of enviro~u-~ental health concerns identified above, there are many others which appear to be unique to st~cffic local areas, "l'~ese typ~ of probler~ may be more widespread than indicated here, but simply not studied extensively. Several of these are identified below. Arsenic in Drinkin$ Watt" 8U~G^RIA. High arsenic concentrations in drinking water have been found in Pazardjik, downstream h~m the copper smelter in Srednognrie. Arsenic levels of 1,440, 389, Table 3.20 ~mum me~ured nitre levels, Belatus, 198/-1990 B~I .... 1712 Gome~ 420 4~ 420 Gt~no 420 ~2 420 M~sk ~ 129 210 Mogilev l~ I~ 11S BATCo document for Mayo Clinic 27 March 02
Page 55: 39000936
1,072 and 470 micrograms per liter have been measured in the tributaries of the Topolnitza R~ver upriver from ard~k. The Bulgarian standard Ls 50 micr~ams ar~nic per liter in surface waters, in some wells near the Topoh'dtza reservoir, arsenic was measur~i at levels betwee~ 19 and 286 micrograms per liter. These water supplies had apparently been dosed for human consumF- lion, but there was coni'licting information as to whether this water was still being used to irrigate crops. A study done in ]985 revealed that 20 ]~rcent of the soils in the Pazardjik area had arsenic levels exce~ing the standard of 25 parts per million. According to local experts, Water contaminated with arsenic h*om the copper smelter is used to irrigate farms near Pazardjik. This is a rice growing area and the land is Hooded for extensive periods of time. There is little information re~arding the public health response to the arsenic problem in Pazard~i]c. II was claimed that since 1985, the smelter was emitting less arsenic than in the past, and that soil arsenic levels had been declining. However, we saw no quantitative in(urination which validated this claim. Moreover, it was said that water [rum the Topolnitza River was being used less now in rice production than it had been before. HUNGARY. Arsenic in drinking water is a widespread public health problem in Hungary, especially in Bekes County. A report from the Hungarian Academy of SCio ences reports that 740 of 3,000 settlements in Hungary do not have potable water because of high nitrate and arsenic pollution; about I| percent of the population lives in these s~ttlements. In 1981, it was estimated that 450,0(}0 inhabit- ants of 6 counties were drinking water contaminated with arsenic above the standard of ~0 micrograms per liter. About 270,000 of these people were living in 31 settle- ments within Bekes County, and drinking water with arsenic levels 2 to 3 times above the standard. A study was car~ed out in Bekes County between 1971 and 1957 to learn the health impacts of ingesting arsenic- conlaminated water. The researchers surveyed inhabitants of Bekes County who have used dcep-we]l water contaminated with arsenic throughout their lives. A total of 20,~00 inhabitants of the neighboring rural area with uncontaminated drinking water served as controls. The childhood sample included approximately 5,000 chil- dren exposed to arsenic in drinking water and 5,000 not exposed. Children with hair-arsenic levels g~ealer than I miillg~'am ~r kilogram had higher rates of bronchitis, sillltls, intestinal co[ic, arsenic melanosis, and arsenic kera- lUSts than children with lower hair-arsenlc levels. The rate of stillbirths was 7.68 per 1,0~ live births in the areas with arsenic-contaminated water compared with 2.84 in the control area. A study of adults, which covered the period 1978--88, concerned various aspects of mortality and morbidity associated with arsenic exposure. The rate o| death ~TOm heart attacks (myocardial infarctions) among those aged 30 to 39 of both sexes was reported to be 20 percent higher In communities with high arsenic levels than in the control communities. The local authoriHes th~nk this may be related to degeneration of the small arteries (arterioles), a patholo~" of acute arsenic poisoning. One of the main public health responses to the problem of arsenic has been to supply water in plastic hags. in Bekes County, all children under the age of 14 years get two liters per day of bagged water if the arsenic level in their natural drink~g water is two or more times the standard. ROMANI,~. An area of kigh naturally-occun~ng arsenic in ground waler extends from Southeastern Hungary into the districts of Arad-Lipova-lneu in Romania, where l~bveen 80,000 and 100,(X}0 people live. Arsenic levels in water in this re~ion can reach 2-3 times the standard of micrograms ~ liter. The ~glon also seems to have unusually high rates of skin cancer, However, no sample surveys of health status have yet l~,en done in the area. In[eclious Disease and A4fcmbiologicall~ Contaminated ESTONIA. Problems with water quality in Estonia has led to rest-tic'dons for recreational use and to replacement of certain pollut~ local drinking water supplies with more expensive, distant sources. In Estonia there are 24 public beach areas, of which ~0 have been dosed to swim- ming since 1989 due to microbiological pollution. The worst affected areas are coaslal areas near Tallinn, Parnu, Ha~psalu, and Kohtla-~arve, two locations on the island of 5airemaa, and a lake in the 3r~1~andl distrlct. In eac~ case the problem is attributed to untreated or inadequately treated sewage. Becausa swirm~g is forbidden, the health impacts due to h~ contarninated water have been minor. Only one pa~on is believed to have become ill from swlnm~ing in the past three years. Public health authorities are concerned about beach closures because the~ b~lieve that swhnming important for opHmum development of the respiratory organs in ch~dren. Thus, they tend to view beach closu~s as a tl'u"~t to health protection, similar to that causod by a shortage of vaccines against childhood diseases. Lri~L~, The public health signi6cance of mic~obi~ logical contamination of well water in Lithuania unclear. There has been no evidence of large-scale water- borne outbreaks of infectious dLsease, but there is some concern that water may be contributing directly or indi- rectly (through contamination of food) to the 1000-20~0 cases of salmonella, shigella, and hepatitis A in L~thuania each year, as well as to giardia, iepto~piro~is, and viral infections. However there is no evidence that a systematic study of this issue has ever been done. Sever~l milk plants around the country have been closed due to unhygienic conditions, but we were unable to get any descriptions of infectious disease outbreaks due to contan~nated water in milk plants. This is in contrast to Lat-~ia, where such epi- den'dcs have been documented. Sewage and industrial effluent contaminate the Ner~ Nemunas Riv~ system~ the Cumnian Lagoon, and the tic ~ea coastline, making these unfit for recreational use. The Nemunas River is contaminated at its origin in Belarus by untreated .sewage, and receives i~dustrlal disc~ of dyes, detergents, clu~me compounds and other chemical substances along its course. The Neris River, carrying al~ the residential sewage (untreated) from Kaunas, joins the Nemunas dov~astre~m, l~:ause of this high pollution BATCo document for Mayo Clinic 27 March 02
Page 56: 39000936
load, beaches alanS the river system in Faunas have been permanently" closed. Dowustream of Faunas, the Nemu- has River r~eives enormous amounts of industrial w~te f~om two large, late nineteenth century pulp mills in the Kaliningrad Oblast, The river then flows into the Cumninn I.~goon, where raw s~,age from Khipeda is dumpod, ~ong w/th 24 n'~Jon cubF" met~ of effluent p~r year f~m a local pulp and paper mill and smaller amounts frem a battery plant, including manganese and mer~u7. Curiously, as of 1992, there were no resMctions on fish- ins in the Curon/an L~goon. Elevated arsenic leveh have been found in two fish,~mples in the past three years, but no other sig11~cant metal concentrations. Officials from the Ministry of Environment tell anecdotea about fish with tumors, but persons from the Mun~pal Hygiene Center, who are responsible for inspecting fisl~ c/aim they have not dete~ted d~seases in fish. The biggest preblen'~ they perceive are massive fish k~lls in the summer due to blue- ~-en algae blooms, due in large part to the organic wastes dumped into the lagoon. The most noticeable impact of contamination of the Nernunas-Nerls-Curonlan water system so Jar has been beach closures. Between 43-54 percent of water samples taken from beaches near the outflow tailed to me~t the microbiological standards for bathing water. The three beaches closest to the outflow have been closed for the full season in recent y~rs, preventing potentially serious out- breaks of waterborne infectious diseases. There was also one beach closure at Palanga, a popular tourist resort area several kilomete~ ~rther north along the Balt/c. LATVIA. The best-documented human health problems from environmental pollution in L~t~a are due to contam- inated drirddng water. More than most countcies in the region, Latvia relies on surface waters for a large share of its driakinS water. In ~cent years, there have been several outbreaks of waterborne infectious disease in the country. In the winter of 1988/89, the city of Riga ran low on alum, an agent used in the coagulation and purification of drinking water. This was critical because approximately Box 3.2 Environment and health in Russia At pr~ent there ,s~ms to be a disconnertion between the data and information flows which drive policy debates on the environment In Russia and the supply of environmental health evaluations which are of sufficient quality to in/arm the~e debates. At the level of policy.making, reliance is bein8 placed upon routinely collected data, usually s~arding mortality, which is aggregated over large, adroinistrativel)~ convenient regions and not acros~ geographic areas with coramon environmental pollution problems. These data reveal large di/ferences in II/e expectancy amonS the obiasta and autonomous republics. For example, in 1989 there was a 5.3 year life expectancy di/fer~nce for males across the 73 admintstrativ~ regions with valid death certLqcation. Certain indexes which r~flect these differences, such as cause specific mortality rates and "pt.rson years of life lost before age 70" have ~n con'elated with variatmns in "living conditions" and also with environmental quality aches administrative regions. These analys~ hev~ revealed that the mea- sures of living conditions are much stronger correhtes of mortality than are the measures of average ambient air and water pollution. There are obvious methodological problems with averaging measures of air and water pollution over areas with different pollution experiences, all of which would tend to strongly bias against detect~S an environmental elfect. We have come to realize that environ- mental impacts in Central and Eastern Europe are strong,st tn relation to morbidity and not mortality. Thus, the~ correlation analyse~ are no l~t at all of the impact of environmental pollution on h~alth. Nonetheless, in a country as diverse as Russia, where living conditions encompass a range ~vom modern to primitive, the basic aberration that life eapectancy variations are primsflly a function of living conditlon~ is likely correct. But inserting it Into the dis- cussion about the impact of envlronmentel pollution on human health has been most unhelpful. The policy corollary which has been drawn is of the form: socioeconomic conditions are more important to addre~ than envlmnmrntal conditions when it comes to health. The dichotomy is counterproductive. No-one se~ms to be asking the question: can environmental health problems be used to help set inv~tment priorities in a way which could protect health at the same time as promoting economic development which will improve living conditions? The other strik~g aspect of the cen~nt pol/cy dbcu~ion is how unlike the public perception it is. Russia has been portrayed in the m~lia, and in book length ~xpos~.So as a country with wideslmead health problems due to unconh'olled spread of ionizing radiations, unt-mated sewage, contamination of water and soil with p~tictdes and chlorinated organics, and air polluted with dust and organic substances. There does not se~m to be any agency in Ru.~ia with general access to dam and Information which is evaluating these elaine. Nor does there seem to be any agency with a mandate to do so. On past experience in Central and I/astern Burope it is likely true that some, but not by'any means all, of the health claims have b~n eaaggerated. Thus, the Job of collattnS and critically appraising information linking envh'onmental pollution to human health ~k ac~ss the country is of top priority, both to address the gulf hetwesn public perception and policy analysis and to mobilize environmental health information for policy making purposes. It is not clear whether or not the principal environmental health problems in Russia are the same as those in the rest of Central and Eastern I:urope. Russia's size and tremendous diversity Impose significant obstacles to generalization and the job of collating and ana- lyzing existing information will be long and pn~racted. This task is made daunting by the fact that relevant information has, according to one estimate, been generated by more than 100 dlffenmt institutes around the country. Judging from the experience In Moscow, these institutes are affiliated with a wide range of different guvernment ministries and may have crnss-aff~iations to either the Acad- emy of Science or the Academy of Medical Science. En~a'onmental health information in Rus~ht includ~ an ad ha: mixture of analys~ of routinely collected data and studies o! ape- dally identified populations. They cover a wide range of leveb of geographic aggregation, from huge edministratlve regions to nar- rowly defined neighborhoods and communiti~. Th~r~ is reason to b~lieve that a signilicant amount of this in/ormatlon is useful. In one summa~7, published in the English language journal The Science of th~ Total F.a~imnment, a variety of stodles of lung cancer. respiratory disease, and child development in relation to envi~nmentei pollution were briefly described, although in too little detail BATCo document for Mayo Clinic 27 March 02
Page 57: 39000936
one-half of Ri~'s drinking water comes from the Dau- gave River which is heavily polluted with multiple bacte- ria and virus~ from upah~m di.~.harses ol sewage. Because of the alum shortage, Riga's drinking water was incomplelely Izeated, and a waterborne epidemic of hepa- title A broke out, lasting appm~mately 2 months. Between 5(X} and 2,000 people fell ill with the disease. Hepatitis A was not suspected and was not detected in the wat~ m'~fil samples w~-e s~n~ to Moscow for by electron microscope. Subsequently, a '~oil water" order was issued wl~ch helped end the epidemic. It is now the practice of the Republican Hygiene Center to tes~ drinking water for hepatitis A, but since i~" takes r~veral days to obtain results, an outbreak could occur before the contamination b deiected. Because coagulants continue to be in shor~ supply, this is a ~erious concern. Contaminaled surface walers have also contributed to foodbome infectious disease epidemics. One dramatic example concerns a milk plant in Jelgava, where technical water became mixed with drinking water, contaminating milk bottlea. Sterilization did not con'e:t this problem, sinc~ the pasleurization equipment was not func~oning at the appmp~te teml:.~ature. An epidemic of 5,0(D-6,000 cases o~ dysentery occurred as a n~'ult. The above two ep~xles are the most well-known but may not be the only ones. Shortages of alum occur ~ quently in Latvia, and sporadic waterborne c~ses of hepa- titi~ A and typhus are suspected. In addition, leptospirosis has become endemic in Lalvia, a serious concern because 18 to 2~ pen:ent of cases are fatal. Although leptospirosis is usually spread directly by rodents, two recent cases among bathex~ were traced to leptospira in a small tribu- tary of the Lailupe River near Iecava. CentaminaEon of the Daugava and Uelupe Rivev~ ~om sewage and industmiai emissions have also led to beach clo- ~ in Jurmala, which is one of the prime summer recre- ation areas on the Baltic Sea coast. During the !m~,-indepen- Water samples were not E~luentiy taken at the beaches, and ~blic health officials were reluctant to take ac~ons which Box 3.2 (¢onEnued) to evaluate their validity. During a short vlslt to Moscow, some use~ work on kidney disea~ in relation to cadmium exposu~ in children could be identified, and several important investigations oJ occupational discase |oond. Taken together, the~e investigations have not been part o! a coordinated s~'ategy lot the Iden/fflcallon, evaluation, and control of liu~ats to human health from env~n. m~ntal pollution. The re~llt is that, at this time, it is dffli~ult to mahe Imy general statement'~ about which s~u~'e~ of poUution have had the greatest impact on human hen.lab or to estimate what the magnitude ol the impact might be. ~ means that the criterion of human health protection cannot be effectively ~ tar priority setttng by envtn3rm~ent~l agendes unEl the enrichment and health infrastructure has been/urther developed. ~.veral ad ~ Iist~ of Iocatious thought to have significant envl~onmtmt~! health prob|em~ in European Russia have been made aveiiahle to us by individuals and g~ups in the country. Two of thin I~ ~. ~ the categorte~ of health probinms, ~otmd in AJmex 4 of ~ report, which have been ust, d i'or the rest of Central and Eastern Europe. The categories ~eem to be relevant to Russia because large numbe~ of commun|ties were found to llt each of them. However, it would appear that the 1~ were not compiled on ~e basis of ~y~tematlcally evaluated information about health statu& For the mini part, they seem to he based upon inference~ drawn from ambient air pollution and emi~ion data and are L.~'ouslqent with one another. D-dring the World Bank mission to Ru~iao no individ- ual or aSency with acce~ to su/ficient information could be found to evaluate tbe~e lists and resolve the contredidinn~. Thus their ~'~LibiLity ls low in comparb, on with other ini'oraut tiou which went into compflin8 the I~ta of affected locations found in Annex 4. Notwithltanding the ~riou~ reservations der, crihed above, the tallowing impre~inus are defensible on the barb of turret iniormalion. I R~spire~or~ prol~ems, both ch~nie and acute, are l:nt'valent in a~uxiatlon with air pollution in vaban and industrial loca~iona in Eusopeen Russia, Compared to the x,~t of Cenhal and Eastern Europe. the profile of air pollution sources of 8~eatest concern would appear to be nmre like Bulgaria than like Poland or the Czech RepubLic, in that sulfur dioxide from coal burning is rehlively inslgnif- kant, while specific point sources of organic vapo~ and irritant genes from chemical planLs and polycydic ammadc hydrocarbons from petroleum indus~es appear to be more si~q~icant. Dust ia a signi/icant air pollution concern in Rub/a, at it is across the re'~t of Central and Eastern Europe. 20vcr~xT~ure Io ~ead in children has been documented (using measth-ementa of lead in hair) in the vicinity oI ~everal hrge indus- trial facilities, indudin8 a lead eme]ter0 lead-cedmium battery phnt, and a storage battery factory. It is unclear whether or not hans- portalion sourcea are • sigr~cant sou~.-e of lead overexpostm~ in ch/Idren. More generally, there is reason to believe that health status in • large proportion of communities adjacent to facifities emitting me.tab, organic cbemlcab, and pea'talcum prnductz is being affect- ed by the'~ emissions. 3 There is partlcu.hr concern about ex-po~um to/en/z/n,g rad/at/4m in commtm/lies adjacent to mi]itary-lndustrlal lacilities in Russia and risks of cancer mortality and adverse repr~luclive outcome. At pr~ent, the~ concem.~ are ve.o' dlffioalt to eva~uate. The ex,perl- ence et Cbernobyl so tar hat Ix~n that careful .dos~ a.x~.~amont and epidemlolog/¢a] investigation has helped to put st~/d upper bounds on the health concerns there. A simllar approach is needed in the communities of concern in Russia. 4 Several w'eLi-designed studio of cohort-, of worke~ in Rusaia exposed to known industrial toxlva haw ahown pattem~ of exce~ morality characteristic of tho~ substanco. Stodies o~ ~xpo~me to cadmium at work have shown prodigiously high levels of long- term overexposu~. Thes~ studies suggest that working conditions in many Ru~laa work places were significant soun~s o~ overea- Imstu~ to their workers before the recent economic cni~p~e. It is not ~ear how the patterns of exposu~ here changed m, er the h.st ~everal yea~ of economic change. 5 There is rea.~on to beLieve that ni~retes In dr/nk/ng tinter a.~ • prevalent c~rtcerrt in Ru~ia, Arsenic, pes0.cides, and Petr~eum prod- uclz In drinklng water a~ also significant con~rns, but may he Im prevalent. OO CO BATCo document for Mayo Clinic 27 March 02
Page 58: 39000936
Table ~ Water supplies not meeting mlc~'obiolog[cal ~nd chemical standards, Llthuan/a Drinking water:. Centralized 7 7 Well 41 R~reational: Rivets/lakes 40 41 ~an 27 ~'~ 25 17 46 63 ~ Httt~man 1~2 (c) might affect the ~ vaeations of those who went to Jur- mala. However, during the I989.-91 summers, ~uch orde~ have bec~me common in ]'unnala, lasting the who/e 1991 bathing ,easot~ Cases of skin rash havebeea repotted among some of those who have igno~ the stop swimming order. Bathing has also been f~tuentiy prohibited in the Venta River (Vantspils re, on and Kuld~ga), the Daugava River (Jek- abp~ and Plaunas) and the Guuja River (Cesis ~. BELARUS. A study by the Sanitary and Hygiene Research Institute of the Ministry of Health found that 48 per.zent of the rural population was supplied with sub- standard drinking water. Thirty-five percent of shallow wells did not meet the bacteriological standard of 3 E-cull per flier. Not surprisingly, rural populations suffer acute intestinal infections at rates higher than urban popuJa- tions. Regression analyses relating variations in water quality (measured as the percent of wells below standard over 5 years) with frequency of intestinal infections, have shown water quality to be a highly statistically significant risk factor for intestinal infections in all oblasta. Problems Unique In Specific Locations Es'romA. Since the late 1980s, 2-8 percent of children in Sillamae have had problems with baldness which, in many cases, disappeared when the children left the area. In Narva the prevalence ranged from 2..3-4 percent and in Kohtla-larve, ~'om 0.6-4.7 percent. In Tartu, the compara- tot community, the prevalence of baldness was 0.8 per- cent. Therefore, this has been variously described as a problem of Sillamae or as a problem of the whole area. Because the SilIamae area had been under direct Moscow control for at least a decade, local public health officials were not certain about the pa~erns of environmental exposure and the cause of the problem remains a mystery. LATVIA. Leipaja is a seaport on the Baltic Coast with population of about I14,000. [t was a commercial port until 1966 but was made a closed city by the ,Soviet mill- tary from 19~-76, The miti~-7 base occupies two thomand hectares of town and hou.sed approximately 15,000 and 2~X}O family m~ in early 1992. The base dumps beaches on the north side of town. Health authorities in Lel- finns along the "l'allinn line" and at the air bases at Sknmda a~d Vainede. Until three years ago the Soviet military con- trelled all data and information on electromagnet/c fields in the a~a, so public investigations are only two yearn old. In November 1990 the hygiene center took measummants of the eleci~magnetic fields at a school in the Ezerla'asts neighbor- hood located within 200 meters of a point sou_nce. The field intemity was reported to be 8 times the Soviet standard (the Sovie~ sta~iard is similar to the European standard). At two homes which were boot approximately 2,500 meters from the same point source, the field intensity was reported to be tlux~e times the standard. During the suramer of 1991 the mil- itary built a fence between the point source and the ~ neighborhood which reduced the field intensity at the ~.hool to twice the standard. Investigations and observations of health problems among people living and working in the Ezerkrast~ neighbor- hood and other a.teas near major radar fadlities are as follow~: • A study involving 180 children who had lived for at ]east 3 years in Ezerkrasts or another exposed neighbor- ho(xi found that 60 Percent had enlarged thymus glands (an organ impor~n[: for the body's immune function). In addition, 60 Percent o| a sub-sample of 34 children had increased lympho<yte counts in blood and other "non- specific" evidence of increased immunological activity. Among the f~l ,sample of 180 children, problems with h~adaches, nervousness, and lassitude were reported much more frequant[y than expected by examining physicians. • Routine investigation of all "well babies" less than I year old In Leipaia revealed that tho~e living on the mil- itary bases had a prevalence of thymomegaly 20--30 per- cent higher than those living off the base. • The Institute of Oncology examined 481 blind adult', who worked at a sheltered wor]cshop in Ezerkr'asts, within 500 meters o| the radar facility. Of the study subjects, 107 had evidence of anemia and leukope- nia (reduced numbers of white blood cells) and a ~rther 4 had lymphadenitis (inflammation of the lymph glands). • Investigators at the Institute of Oncology report that there is a cluster of leukemia among teenagers at school near the military airbase in Vainode. Further investigation and more careful documentation are needed to determine how environmental exposm'es ate damaging health in this region. One large point source of air pollutant* in Leipaja is the LeipaJa Metal Worker. This steel mill is 109 years old and still us~ open hearth furnaces (most recently installed in |965, long after basic oxygen technology had been perfected). [n addition, its casting process uses silica sand and waste oils for binding which give off carcinogenic products during C~ BATCo document for Mayo Clinic 27 March 02
Page 59: 39000936
pyrmtys~s fnon-oxygen burning). Workers in the plan~: are exposed to nu~ero~ toxins a,~d ca~nol~ At peesant, the plant has 76 worke~ on Paten for perrrtanent disabilo ity. Some of these d.babRities am due to t~uma, but others involve dust-related c.im3nic bronchi~, silicosis from the casting o~ration (wl~ch they say is under-diagnesed due for X-ray quaUty), and lung cancer, likely due to to the above-menl:ioned pyrroly~ts l:~'oducts. The con~nu- nity impact of ernisdons born this plant has no~ been fully evaluated. The major embsions are sulfur dioxide and dust, containing relatively low concentrations of metals. Three years ago radioactive dust was discovered on the rite. The plant, which is largely a recyc]ing faciti~, wa~melting down 5oviet military eclniFment. The plant is no longer doing this, but the waste materials on the site may still be ]~3sing a threat to the health of the local population. A tudque problem exists at the beaches of Llepaja on the Baltic. The heavily used beaches on thcsouth side of ]'oeipaja are littered with pieces of phosphorus wastes, washed up from sites to the south used by the Soviet mill- tary for bombing practice. Small ddldren in particular often mistake the pieces of phosphorus for colorful rocks, and place them in their pockets. These bits of phospho- rous can spontaneously lignite and badly burn the chil- dren. Local pediatricians reported approximately 13 inci- dences in which children received tldzd des~'ee burns to theh" legs and groins in 1991 from this cause. The main concern in the Baltic port city of Venispils is the potential for an explnsion at a fadlity which stores arm~onium, methanol and acrylonih'i]e on site and manu- factures liquid fertilizer from phosphoric acid and ammo- niuJ~. R~il cars carrying raw materials sit on tracks across the street from residences. Next to the facility is oil t•nk farm and a few hundred meters away is a Soviet army munitions dump. This ~txtaposillon of fadIJties was approved directly from Moscow, over-riding lo¢..a] perEtJt- ring procedures, in the 1970s. In 1991, a quantitative risk assessment was conducted a! the ammonium storage facility and fertilizer plant to assess the potential for an explosion there and to see how much the risk could be reduced by instituting a series of technical and procedural controls. The initlal risk was determined to be very high (i.e. a I in I0 chance per year of an explosion involving at least one fatality), but it was estimate<] that a well-~esiS~ed and implemented control program involving engineering and adndrListrative changes at the plant could reduce the risk There is some concern however as to whether such an extreme decrease in risk Ls really possible. For instance, it is not clear that the plan takes into account the explosion hazards represented by the nearby oil tank farm and the mur~tfons dump. ~y, one benefit of the explosion hazard is that Ventspgs has attracted the attention of the United Na6ons Inter-agency Group oct ]7,~k ,A.sse~me~t and Human Hes]th. The Dutch SOVemment is sponsoflng a project in which phy- work with Dutch ex~ to develop an env~onmen~ ~trat- egy for Ven~spils, to extend the flsk assessment a~ manage- ment pzocess to all Fm~s in town, to develop ftuther pRven- tive strate~es, a~d toc~a~e an overall tov~ plan. SLOVAK KEFUeUC Several epldewJological studies have been done among worke~ in alu.m~um smelte~ operations who may be ex~ to polycyciic aromatic hydrocarbons used in the manufacture of aluminum. These studies have consistently demonstrated an ~ risk of bladder cancer among the workers. We are not aware of similar evaluations of workers at Ziar nsd Hxonom in the S]ovak Republic However, a map of bladder cancer inci- dence rates by district, published by the 5lova]dan Cancer Re, try of the Institute of Experimental Oncology, shows that there was a high ~te of bladder cancer among males (although not among females) for the pedod 1975-84 in Ztar had Hronom. These maps help demonstrate the potent/al usefulness of an ongoing cancer Inc/dence reporting system for detectin~ potential environmental health problems which deserve further investigation. Another example of the usefulness of a cancer incidence x~port~g system concerns the coal-~,d power plant at Horna l~itra, which is an important sou~'e of arsenic emis- dons. Data from the Slovakian cancer reglsm/, 1975-84, ~how that the popular-ion living in the clis~cts around and downwind of the power plant has unusually high inci-- dence rates of non-meJanomo skin cancer. Epidem/o]osical studies done elsewhere have shown an as,ux:iation between exposure to arsenic and skin cancer. Increased levels of the disease appears in both males and females in the conti~u- ous dist'dcts of Mart~ and Priev/dza. Lung cancer and neurolo~cal diseases have also some- times been assodated with exposure to arsenic in epide- mlolo~ical studies done ebewhere. We have no dat• on the incidence~ of these problems in the region near Horna Nitra. However, in 1977 one Slovak investigator Published an extremely interesting paper which showed hearing loss among children llvLqg near the power plant. In this case. the noise f-Rquendes were 125, 250 and 8,000 Hz, not the frequenc/es usually associated with noise-Lqduced hear- ing loss. The authors surest that the resul~s may be due to central neurolob, ical damage to the ear. From 1956 to 1984, PCBs were produced by • plant in the Michalovce area for the Czechoslovak a~d Soviet mar- kets. During that time no spedal measures were taken for protect/on of the environment. Liquid waste was reg~dady spi/led into the River Laborec. Solid wastes were put into a local landFJl without treatment. In 19~'/, the local hygiene station found increasing levels of PCBs, formalde- hyde, and nitrates in water in the Laborec River and the Sirava reservoir (which is a recreational lake). In 1978, nitxate levels were in the range of 44-120 milligrama per liter in these waters. By 1980, formaldehyde was found at a concentration of 0.9 milligrams per [~ter in drirddng water, which was three times the standard. PCBs in the Laborec River reached 15.5 miero~rem per I/ter and r~nged from 1.5 to 2.9 microg~ms per liter in the Simva reservoir. In the Michalovce water supply, the concentm- tions of PCBs ranged from 2.3 to 6.4 mi~grams per liter. In 1980, a pathologist in Michalovee noted that there was • very hish incidence of Potter's Syndrome among L'dants born in the town, • condition of congenital under- development or non-development of kidney~ which has been sissociated with PCB exposure in scientific research. Twenty cases of Potter's Syndrome had occurred in 47 BATCo document for Mayo Clinic 27 March 02
Page 60: 39000936
BATCo document for Mayo Clinic 27 March 02
Page 61: 39000936
M/ch~ovce bet-~,en 1975 ~nd 1980, nine of them ~ the I~ d~ wat~ was s~ppU~ ~m o~er ~. pl~t stop~ p~u~g ~Bs. How~ another 2~ to~ wai~8 fur ad~ta By the late 19~, ~leve~ ~ ~e 1~I wat~ ~ ~d dmp~ to negli~ble leve~. How~, ~ ~ve ~ist~ in the b~ast ~ of women ~ ~ a~ ~ well as in the ~t ~sue of bmpi~ pa~en~ w~ t~t~, ~e average lev~ ~ve nng~ ~ ~r ~lo~am and ~e ~ me~ v~um ~ve rang~ ~m 10 to 27 ~ ~r ~o~ Back~und leve~ world ~ Mlo~am. H~lth, ~t ~ whi~ no H~lth lu~on, the ~ of d~ and v~ complex. ~ addition to ~e co~o~ su~nc~ iden~ pre~o~ly ~ the ~on on ~ q~- i~, them ~ a va~ of o~m con~ons ~ ~e a~ (~ ment~ ~ogen ~on8 the ~ly~¢ ~c h~ ~r~n ~a~y. Ex~s~ m ~ly~c ~c other ca~oge~ ~y ~ve ~v~ce. ~e study, w~ ~ a ~ of biolo~ bl~ ~mpl~ ~m ~id~ of GH~ce ~ ~to~ ~d (ound t~t ex~ to ~ly~c ~Hc hyd~ was ~at~ ~ sl~t DNA =ddu~~ (i.e. ~ly~c~c ~¢ hy~ ~ ~a~ ~ ~-DNA addu~, ~mal mu=~on, pm~d~g a molar ~cer ~d ~p~u~ve ~ of ~to~ce prance fo~d t~t ct benz~a)i:n/rene were more likely to be mulalenlc in one m" another form of the Ames mutagenicity ~y (see Table 3.22). Mutaseni¢ u.,-ine is an indicator of exposure to biolosically significant doses of c-an:inosenic substances. Mutagenic urine is rare among people without a defined source of exp<mure in North Amer/ca. Benzo(a)pyrene which is not nece~ari]y' the only' can~ogen in the air, but Ls ]iY, ely a cova~iate of the total airborne carcinogen load. By' including a (relatively} unexposed control group, sta- t~c~ily sign~.ficant increases in the proportion of mut~- ~/c samples can be seen. Concent~at/ons of benzo(a)py- rene the soil of garden plots in Katowice Province can also be very high, up to 1,000 l:~Xm per bill/on in some places. Thm-efore, soLl and foodborne exl~su.rm may conu'ibute to the mutagenic load. HU~OAXY. Data show that in A~ as of the early 1980s, where the aluminum smelter was a significant source of l~-nzo(a)py~ne emissions, ambient concentrations 4.8 nano~'ams per cubic mete~ appmxln~tely five times higher than in the conuol town of Papa, Monitoring data r~veals a marked season~l var~tion in the mutagenicity ah'borne l~cu]ates, with high levels of mutageni¢ activ- ity occurring in the winter and lower lever in the summer. Also, the character of the mutagenic n~sponse in bioas~y systen~ e.hanges with the seasons, suggesting a d~erent mixture of chem/ca~ con~buting to the mutagenic load in ~.mmer and wimer. There are Mgh levels of votatile aromatics in the the dry of Vac, although Vac is a compararivelX small set- tlement with motor vehicle t~affic ~ows well ~low those of l~udapest (~ee Annex 6, Table A6.6). Ambient benzene levels at five monitoring Ioca~on~ in Va¢ exceeded the messx~-d concentrations in fo~ n~ajor Canadian citie~ during the late l~BOs. The range of concentrations for tol- uene and xylene we~ also hi~,her than in Canada. Since vola~/e ox-~-~/c~ have ~ wide var/ety of tox/c ef~-'~s, p~r- ticularlx upon the nervous system, finding ~nexpec~ed]X l~i~h concentrations in the air in a cSty with no obvious RO~;IA. Carc~o~enic substances in concentrations exceeding the Roman/,xn standards have b~en measured in water smnples from 32 of 41 distrlc~ in the count~ and in air samples tn :26 o~ 4~ dist~cts in the count~ and in '*menu samples" of food in 23 of 41 distr/cts in the country. Cl',lorinat~,d pesticides (which in~ude linden, HC.H, xklrin, d/eldrla, and DDT and its breakdown products) have bee~ detected in I00 tap water samples in the of the southeastern l:~r~on of the coun~'y s~pplied with d_,-bd~g watt" ~mm sur~ce and shallow g~ound water Table 3.22 Mutasenie u.dne BATCo document for Mayo Clinic 27 March 02
Page 62: 39000936
mu~es. Alt.~ugh DDT has been banned for use In Roma- nit s'mce I~74, it ls ~ predu~/n the country for export (one plant is in Rim~cu Vdcea on the Olt River, • of the Danube) and there may also be a black mm'ket for it. 13~nking water in 73 percent of the Mmpled towns had total chlorinated pesticide levels above the Romanlan (and European Community) standard of 0.1 m|crog~-an~ per liter; 13 percent had concentrations above 10 m/c~sran~ ~ titer. Bample~ taken from towns along the Danube were among the n~ost contaminated. Samples of mother's milk taken according to a WHO protocol in 1984/85 showed DDT levels of 2-8 parts per minion and HCH levels of 11-12 parts per minion. Adi- pose t~sue levels of DDT in several samples taken adults were 8-34 parts per m,illiono compared to levels in the West which rarely exceed I part per minion. Drinkins water samples taken from three tmvns along the Prut P,h.e~ in 19~89 had t~h levels of total chlot~ated pss- t/cideso rang~g from 12 percent to 4~3 Pan:-,nt of the standard. Chlor~ted pestiddes In drinking water were also a .~'ious problem tn Ttmosoara. Total chlorinated pesticide levels in the Beg• R~ver ranged from 0.3-1.0 micrograms ~ liter at five ~mplin8 locatior~ and average micrograms per tlter in tap water.samples in 'l'unou~ra. ESTO.~"/A. Contamination of groundwater, mainly with oll preducts, has made it neeessary to supply many towns and cities in Estonia with drinkin8 water from alternative sources. Rakvere, Tape ~.nd Kure~saara, Tamsalu and some small .settlements near Tartu all rely on water trucked in from distant ~ou.rces because of groundwater contamination. Drink~g weter for Kotia-Jarve is piped in from the Nerve River because groundwater In the area is contaminated. In Kivioli0 an industrial settlement near Kohtla.Jarve0 hydrocarbons have contaw.lnated the ~oil and the groundwater. The w~te pile at 5lantsechim in Kohtia-Jarve i~ a serious so~ce of water pellution. Leach•re from the pile cuntam/- nstes the Pur~ l~ver with phenol to levels 300-1500 times the st,~ndard of 0.001 milligrams per liter. ~ discharse ha~ kited all the f~h in the Puree River tnd in the I~htla ~ver into which it feeds, as far as the Gu~ of Finland. The Baltic and Estonian Power Plants are also ~ of water pollution. Both plants discharge cooling water into the Nerve River. In addition, higtdy alka~e runoff from slag heaps (pH of 12-13), contaminates the river. The Maardu chemical plant on the outskirts of Talltnn discharges phosphite and ~ul~ate into the Baltic Sea (phesphite concentrations can be ts h/gh as 2~0 mtlll- gram~ per l/ter in the receiving water). It is suspected that the chemical and met~a.Uur~cal works in Silltn'tae dLs- ch~e radioactive su~tances into the l~ic. There is also concern in Estonia about water pollution due to fertilizer nmoff and runoff from angel feediots. of air and water pollution of c~cer~ ~or human heath. The pulp ~ i~ a ~ource of ammonia tnd sulfur dioxide emb- ~ The battery plant and m~at pack~ plant both emit pollutants. The sh~p ~ fa~/~ty pailut~ the air tnd water with dust and paint residues, Including a~nlc, and ls the i~.ely source of a~e~c o<~,sionally detected in F~sh. Fm~ly, ~ is the poten~l for a cz~tmpi~c explosion due to the ur~fe handling of chemicals and 8;rain (whose 8;ases can abo be expk>sive) being loaded and unloaded at the ~ and In surface water contamins tion in recent years. A ma~or acci- dent occurred in November, 19~0 when a hcto~ in Be~-us • ~cidenla]ly relea~d 8 tons o~ cyanide into the Dau~ava River ups~eam of Daugavpi~. No wan~g w~ give~ to downstream users, but a la~e f~ k~ was ~xn*ed to • utho~t~es in Daug~vptls in time to c]nse the water supply for a few days. One per~n wa~ hospitali2ed alter eatin~ a fi~h he fo~md dead, lm~.~nably from cyanide poi.u:ming. Untreated chemical w~tes entered the Daugava River from Belarus in two other incident, In November 1~91 and lanu- ary" 19~)2. Fortunately, no ~me wa~ hm't from the incidertts. C..~CH AND SLOVA~ REPUgI2CS. Metal concentrations in drh'tking water samples taken in the Czech Relmbllc befween 1984 and 1986 varied by as much as ten-fold for many of the metals. In ~me areas, drinking water sam° pies also contained mat•genie substances. Between 5~ and 77 ]x, rcent of drink~[~ water samples f'mm var/ous trial areas showed rout•genie activity in the Ames A.~ay, an Indication of the presenco of car~:~ogens. Oth~ data showed a high level of rout•genie activity in river water near the waste outlet from a chemical plant continuing downst-ream for several hundred meters. Such high metal concentrations and rout•genie ac~vity in drinking water and other surface waters may be harming health. Ui~,AI~. I-I/~h concenU'at~on~ of benz~a) pyvene have been found in the ambient air of sove~l ~ Ukrainian cities. Near main automobile m~tes in Kiev, concentrations ~om 1.3 to 10.6 n,mograms l~n" cuhic mete~. Nem'urban point coblc meter. ^ ~.latively high per~mta~e dmutageni¢ activ- Ukraine. As Table ~.23 sho~s, h~er levels of muta~,,e~ic activity have been found in air in climes which have Contaminanh; in Food Deta on contaminants in fo~d were available from two coun~es in Cenh'al end Eastern E~u'ope: Lithuania and the Slovak Republic. Ln'HuAJ,~A. Table 3.24 provides a summary of available information on contamination of food in Lithusnia. The table ~hows that 0.~--I0.2 percent of se.mpled iten~s have levels of pesticides, metals, and nitrates exceeding the st•n- dud. While this information is insufficient to make ~ e~ces alx~ut human risk, it is • ~ indicator of the degree o~ food conta.mination for compari~on.s over time. Pubtic health o~c~s do not ~ that pe~dde c~ntami- nation in food and water is currently a maior problem, b~t they ~ concerned that pesti~de use ~ in~rsase whe~ BATCo document for Mayo Clinic 27 March 02
Page 63: 39000936
Metillur~c~lI 12-19 Chem,lcal 4.17 Control 2-7' aSr/culture l~ priva~ed. At pn~sent, the country does not have • comp~]sory dec.laratlon system $or pesticides. However, the mc~ ser/ou~ problem wi~h food conmm- lnat~on at present is mic~b|ological conlamina~lon in pro- ces~lng plants. For example, about 36 pe~-ent of rtTo~'d acute dysente~T in 1~0 was tran.smitted by contaminated milk. The He~d of the Hygiene Department ~n the ~ try of Health estimates that approximately 37 pen:~nt ot~ shiSella infections ar~ due to contaminat~l (ood, although what proportion is due to food indushT hygiene condi- lion, as opposed to food-handler carelessness, is not dear. $LOVAX ~Pt.reLIC. High levels oF Sl~ Re,bUt ~ 1987 ~u~ 1~ (~ ~p, ~u~out the f~ ~ as ~tly as I~, ~though it ~ n~ ~ ~ ~ a~ ~ the ~o~ v~ s~ce 19~. Ta~n tog~her t~ o~a~o~ ~- ~ silent l~! va~o~ ~ ~ to ~ of ~o~ hy~ w~ ~ ~ ~ h~ ~t ~d m ~ ~ ~. It ~ not s~g wh~ ~ m~ ~ ~ done on h~ 1. A nitric acid dige~tlon method was used to measur~ lind in soil, which consistently gives lower ,~u~ than hyc[mcldoHc acid digestion. Table ~.24 Food qmdi~ in Llthu~ BATCo document for Mayo Clinic 27 March 02
Page 64: 39000936
or bacteria have bee~ di~ctly implicated in a small hum- Imr of episodes of human disease in the region. Exlamarm to these contamLnan~s in water, as their counterpa~ in food, repn~sent risks o$ unknown prevalence° magn/tude, and certagn~. Using these generalL,,ations we have used ambient alr, water, and tood quality da~ to identify other places in the reg/on wl~ch have exposm.e pro£~es l~e places ~or wHch we have epidemiolog/cal data, and have produced a sup- pl~menL~y list of sites where envimnmen~l ~posttres might be harming health. These locations a~e listed in Annex 9. Economic Tra~ormat/on and ~vL-onmental Health The level, composition, and resoun:e re~L-,ements of eco- nomlc activity in Central and F.astern Europe m'e changing rapidly, and will conti.nue to change, as a con.~:luence of the economic transformation that is taking phce. From a sU-ategic standpoint, it would s~em most bene~cial to ~ imerventions on those environmental health prob- lems which will Pe~ist a~er the econora/c and slzuctural changes have been completed. To identi~" how environ- mental conditions might change in response to economic transformation, scensrios of ~utuse economic activity in the cmmt~-ies of Central and Eastern Europe have been prepared, based on a care~l analysis of• large number of st~ctm'aL institutional and microeconomic changes that • .re expected to occur over the next two decades. It is expeeted that economic change will bring about a permanent drop In the demand for the output of heavy indusW/relative to national income. The economies of the teglon should be able to produce more final output for the ~ame volume of r~oth,~e and other inputs, thereby reduc- ing the volumes of residuals (in the form of solid, liquid or gaseous waste) that are generated. F'maliy, much of the oldest capital equipment will be s~apped as a result of the decline In Industrial output and the process of industzial restruci~'ing. Even ff old capital equipment were simply Box 4.1 A;rborne Dust or Gases---W'hich i~ More Important? The work de.'~cribed in ~ :~ort has come at • time in which new knowledge is rapidly emerging alxmt the impact of air polJuHon on human health. Of partic~la.r interest b the role of ~rta~ gases and vapors (especially soLktr dioxide, oxides of nitrogen, ozone, and hydr~arbous) in pre<ipitatin8 acute ~piralory episodes and exacerbatin8 chronic bronchitis and asthma. At the same ~e. the Impact of respirable dust on mortality (in addition to Rs role in respisatory morbidity) is being recognized f-rom studies of a variety of large cities in the West with concentration:, of ambient dust which are much lower than in many places in Cent~ai and Eastern Europe. The mo~t recent study, by Do<kery a ,1. (1993), which followed 8,111 adults in s~x U.5. cities for 14-16 yeass and which ad~.sted for age, sex, smold~g, education level, and occupational heMth risks, found that the city with the worst fine particulate air pollution had a 26% higher mor~alRy rate than the city with the least pollution of this kind. Thus, Rom • health perspective, it is difficolt to come up with a s~ong theoretical rationale to concentrate on either dust or gases to ~he exclusion of the other. In practtco0 the list of places in the region v, here airborne pollution threatens human health include some where the primary exposure is to dust some where the prin~7 exposure is to one or more gas or vapor; and many where the prob- lem is • combina~on of the two. This same pattern ho/ds trae for regional hot SpOts, areM with • con.flue~lco of pOint sources, and areas where the ~ad town planning" model best applies. K~owledge of the relative impOrtance of the health lmpacls of dusts ~d gase~ does not give a b~sis to set envi~nmental priorities which would target one and aeglec~ the other. However, even i/the health impacts of dusts and gases is cont~ollia$ the former Ls typically much lower. Strategies aimed at con~llin$ dust wl~le tncidenta~y redu~.ng gaseous emissions are therefore pOten~ally the most cost-dfeCdve. The foOowia8 fable shows lypical co•is of cont~oliing partlculates, ~O2 and NOx emissions f'mm coal-llred plant in the power and district heaKng sc~ors using pOllution ab•tement devices. The ~ults highlight the r~latively low cost of contcoRing particulates compared with either SO2 or NOx emi~lona. "l~pical Costs of controllinE emissions from the power and district hearth M~ ~ W~ ~-~ N~ ~w-N~ ~m Priority shou/d be given to: • fit~g ptr~'u~te cont~l dev~es to plants that cun~ently have no such fac~ties iust~ed; and • repa.~.r~ng or upgrading exislL,~g fad/Rles th, t t ar~ c~m.antiy no~ working to design capacity. BATCo document for Mayo Clinic 27 March 02
Page 65: 39000936
Chapter Four Human Health and the Environmental Action Programme for Central and Eastern Europe The most commonly occurring human health associated with environmental pollution in Central and Eastern Era-ape appear to be: overexposu~ to lead among children, acute respiratory and irritant conditions, c.h~nic respiratory conditions, exce~s infant mortality and lung cancer mortality, abnormal physiological development among children, and methemoglobinem~a. In addition, there are other, less 5equently occon'ing probler~s, such as air and waterborne arsenic over-e~posure~, infectious disuse outhreak.~ ~rom microbiologic~lly contaminated drin]dng water and water, increa~d incidence of thyroid cancers in ,some communities t'oLlowing the Chernobyl acddent, fluorusis near aluminum smelters° and a h/gh probability of disease as~ciatecl with exposures to chlori- ~ted hydrocarbons and pesticides. The locations known to be affected by these im~blems have been listed in Annex 4. However, this is not ye~ a com- l~hensive lisl of ~he pl~ces where similar environmen~ health problems a~e ]Lkely to have occurS. Not all places w~th s'm~r ~vi~nmen~l pellu~On problems have been investigated ~or health risks. And tho~ that have been car- r~ed out have not always been conducted on the basis o~ accepted ~cien~ific methodologies. In some cases health claims have been overstated to others, very ~ p~ol~ have been discounted. M~ny lems h~ve been insu.Cficiently investigated because of short- ages o~ reSOUrCeS, lack of epidernJologicaJ expertly, or lack of concern for ~he heath impact of environmental pollution. The next step in developing env'L'oumental action plans to protect human health must be to identify all the places in Central and Eastern Europe where popu/ations are exposed to environmental conditions l~kely to be halTnlng hea|th. [x)cations have come to our attenHon for a va~ety of reasons: becau~ of health claims, ambient a~" or water poLl~.tion data su~esting overexi>ostu~ to human populations, or because of the pr~ence of known pollution sourc~ in a local area. It is un~ely t~t cant locations would be mL~sed by all three approaches. However, there is a danger that some |oc~tions wo~ld be un/ably removed from consideration b~ause epidem/o- logical dat~ was either m~si~ or ~cked cr~iib~ty. To ovep:ome this potential bias we have made some gene~Iizations about the tyl~s of envi~nmental condi- lions chara~er~ing communities with weIl-flocu~ented environmental health problems. L1slng these generaliza- tions, we have identified oth~ communities with ~ environmental proEfles. FoBowing tl~ methodolog~ we have ~dentified the prLndpal types of environmental pol- lution which have affected health status in Central and ,~.astern ]~urope: • ~ in air and soil from lead and zinc smeltere and, in certain cities, ~om t~'a~port due to the use of Jeaded fuels. • Airborn~ dust tram coal burning in households, small-scale enterprises, a~d ~ power and heating plants without or with poorly operating dust ~Iters and metal- ]urgical and other large industrial plants. • Sulfur diaz~le and alher gases from power and indus- trial plants and households usin8 high-sulfur coal or h~gh-sulfu~ fuel oil. The i~ollovfing types of environmental pollution have been defined as secondary with ~spect to human health because they a~e, on average, less prevalent o~ because it is less certain how they a~e affecti~$ human health: • Nitrates in drinking water fn~m inad~juately main- taLnedldesig'ned or Improperly located rural r, eptic tanks, feed lot~ and ag'ricult~ral enterpri~.-~, and Iz~p- prol:~-~ate IertiJ2zer appllcations. • Contaminants in food /ram the inappropriate han- dLLn8 or dLsposal of lead dust, heavy metals, pesticides, polycyclic aromatic hydrocarbons, and ch]ot~.nated organi~ such as PCBs. Many of these substances have weIl-<iocumented toxic properties, yet the human health sis~l~cance of [ngesti0n at largely unknown do~es [s • Other oantaminants in drirddn8 u;atcr ~m the inap- proprJale handling o~ disposal of wate~ c~ntaminate<i with arsenic, viruses or bacteria, pesticides, radionuclldes, • nd chJorinated orgardc~. Waterborne ar~nlc amd viruses 0 0 C~ O0 BATCo document for Mayo Clinic 27 March 02
Page 66: 39000936
m~-apped at rates t~i~l of market economies, mo~ than ~f of the existing stock will ~ replaced by more moden~ more efficient and less polluting technologies within ten years. However, different coun~es In the region witl have diffe~nt de~qt.es of success in transforming the/r econo- mies. with different results ~or the env/mnme~t, in both the short and long run. In some coun~es, old p]ant~ may continue to operate, b~t wi~out major i~vestment~ in new capital or maintenance. These plant~ will not likely improve their environmental performance, and may even do wone. If coun~es export theh" clea~er fueh, ~uch low-sulfur oil, and use poorer quality co~.h-tstead, l:~'~ic- ulate emissions may increase rather than fall. The decen- tra~zatinn of government responsibi~tie~ n~ght encour- age local authorities to make concessions to polluters that would be easier for centralized agencies to resist. More- over, increased car ownership and consumption of con- ~umer goods will add to problems of traffic pollution and munidpal waste. Allowing energy p~ces to rLse to m~'ket lever is e~p~ed to h~ve wvo principel effects on ~r pollution by promoting energy conservation and by shi~dng the position of fuel use away from coal ~nd towards gas and oil. ~th of these should have the eff~'~ of ~lucin$ ~ sions of most air polfutan~, including thos~ of sigr~- canoe to human health. Projections oi how much emLs- sions of ma~or air po]lutan~ ~e likely to fall have been made for (relatively) high and low emission countries in the ~esion, based on aliemative reform ~cenar/os. In almo~! all ca.~s, the initial dec3ines in erosions due to reduced lever of industrial activity after economic liberal- ization are followed by further declines until after the year 2000: the resul! of the combined impac~ of higher energy price~, indus~ai re~tn~cturing and new investment. Tot~! en'~.~ions of particulates and sulYm" d/oxide are expected to decline by 70 percent or more of theh" p~-r~Jorm level by. 2005 in many countrie~ despite recovery of Domes~c Product to pre-reform levels or higher Ln all cases. Declines of 50 percent or more in other air pollutant~ such as nitrogen oxides and ah'borne lead are l~ely. Sustaining the~e decline~ over t~eo and achieving ~hem in certain "high range" countrle~ will involve invot- ment and regulation strateg~e~ that must be actively pur- sued, and do not simply depend on passively re~ping the benefits of economic change. The t'ol~owing secttona di~- cuss the priority investments needed to ach/eve sustained decline~ in ew.iss~ons o( significance to human health. Priority Inves-nenta and Health l~u~ resources for environmental improvement are scarce in CentraJ tnd Eastern Europe, it is necessary to p~o~ties which reflect the ~gency ~d impor~ce environmentaJ concerns. The damage to human hea/th due to exlx~u~ to en~.ronmen~ pollution h the ~r~t envimn- men~a] concern in the ~gion. Evidence ~om selected OECD co-ntries sugges~ that the c~ts of damage to health due to poor envi~nmen~ qua/ity a/mo~t cerlalnly out- weigh the costs of damage to physlca] or natura] ~pital. Investmentz, IX~cle~, and Ins~itutiom/actions w~ ~ ~v~y ~u= ~ ~ ~ ~ ~ ~ ~ve a ~i~e ~ on h~n ~. ~bl~ ~ ~ ~~ d~on due ~ l~d ov~ ~d a~te ~ ~c mp~to~ ~bl~ ~t~ ~ d~ ~d ~ ~ ~ly ~ve ~ble~ ~ C~ ~d ~t~ E~, ~e fo~o~8 ~ for h~ ~ * Con~] o[ lead ~io~ ~m ~ ~i~mnt ~d~ ~ and ~fion ~. * Con~l oI dmt ~m ~ ~nt ~d~ ~t ~ Con~I of d~ ~d g~ e~io~ ~m the ~g of ~1. ~e ~v~ ~d a~o~ ~low ~ i~d ~ ~ ~te ~p~v~ent ~ ~en~ ~n~fio~ at a low ~ 5 ~ up~d of sight ~ten of long~ t~, ~ufion a~t~t ~t~ shoed ~ d~elo~ ~ ~u~ l~d ~iom ~m ~ Z ~e ~on of ~t to ~u~ e~io~ of d~t, smoke ~d ~t, ~d ~n mono~de ~m o~n h=~h ~. 3. ~v~en~ ~ ~w ~ ~ ~ 0r to ~t ~g p~m, ~ ~ ~d h~ol~ ~ ~ to~ ~d d~m wh~ ~e av~ge 4. ~n~ ~ ~te ~e ~ ~on o~ dom~c ~c ~ ~d ~e app~p~te ~ o~ ~ ~m ~mlve ~v~ o~o~ ~ wh~ ~ ~ ~ ~ d~ ~t ~ ~ ~ ~e ~on of ~ ~ a ~on ~le, ~ ~ ~ ~ ~ Mve ~ ~y ~d ~ ~ 4~). 0 0 (DO ~0 BATCo document for Mayo Clinic 27 March 02
Page 67: 39000936
The cost~ of damage to human health caused by such emissions can be la~, especlaUy ff ~hm/affect a substan- tial population. Children are the prkrmy victims o[ expo- sure to lead. Lead exposure interferes with neurobehav- lord development and may affect health, well-being, and comFetenc~ tlm~ghout the liIe cycle. Thus, the coals of lead oveJ~xposu~ in childhood will be in~ over a long period of time and it IS important to deal with the problem as soon as possible in o~er to prevent damage to those bern in the n~xt few yeaz~ Since exl~osu_~ ta lead may occu~ through numerous pathways, reducing the risk of exposu~ will require a variety of measun~ To reduce oh-borne lead dust, lead and copper smeite~ must install dust ~ntrol equipmenL At the same time, to avoid exposu~ to lead in good or water, It will be important to maintain a an'don sani~ire azou~d smelters to prevent soils which are akeady tun- laminated with high levels of heavy metals from being used to grow crops or for grazing. Significant reductions in the damage caused by non- hrrous smelters can be ad'~eved by focusing on plant management and hygiene. Even a cursory impscfion may reveal very simple measures that can be taken Is z~luce wind-blow~ dust, energy losses and other ~ugitive emis- sions. A common pzoblem Is the poor handling and stor- age of metal ores which results in large quantities o~' dust being dis~ibute~ around the sun'ou~ding a~.a. Invest- ment in water sprays, partial (or complete) enclosu~ of stockpiles and conveyors, and careful attention to clean- ing roadways ar~ clear examples of "win-win" measu~s related to good housekeeping. CON'/'ROL OF LEAD FROM TILadqSPORTA'I'ION sObrRCF_q. High blood lead levels have been recorded in several cities in Central and Eastern Europe, making the reduction of lead emissions from transport sources a priori~ for human health. In North America, larg~-scale popu.lation rt, du~ous in average blood lead levels over the past 20 years have strongly con'~lated with policies reducing or elimJ~ting lead from gasoline. Thar~ is b~ood reason to believe that an analogous set af policies would be simi- larly effective in Central and Eastern Europe. PARTICULATE AND SULFUR EMISSIONS FROM 130N AND STEEL PLANTS. Every country in Central and Eastern Europe, other than Hungary, has two or moR large urban areas whose air quali~ is badly polluted by h'on and sleei plants which belch out particulates, sulfur dioxide, carbon monoxide and miscellaneous hydrocar- bons. Much o! the iron and steel industry in Central and Eastern Euxope r~lles upon out-dated and inefficient t~hnolosy which resulls in poor envi~unmental perfor- mance. For instance, open hearth furnaces account for almost haft ol~ crude steel produ~on. The installation of better environmental controls should be an absolute re~luirement for any plant that ~-ceives investment for modernization. Towns and cities with old steel plants have alway~ been among the dktiest areas in any country, whether tn market or formerly centrally planned economies. Ambient levels of paedculates ate espedaliy high, which can lead to Box 4.2 £n~'onmental improvements in the non- [ermua metals industry--Plovdi¢ and Copes Mica The main enviromnental problem concerns endssions of dust conta,i~Jng lead which can contaminate sol/s and affect chilcL.~ in a wide radlu~ around a plant In the plants recently studled--Plovdiv ~ulga.~) and Copsa Mica (Roma~lab--the magn ~om.ces of dmt embstons were: dust c~J.tinn in handlin~ the. metal cor.c~tr-'.tes includIng u~ding I~uc~s or nulway wagons, mixinS and ¢rushinS operations, and ~r.shu'ri~S it ~ the stater plant; ~) wind- blown Iosse~ of concentxates h'om stockpllm; ~nd (c) fume and dust end~kn~ [ram the alater plant, bhat ~ce and other refmln$ operation.s.'/'he wont problems at both plants seem to be associated with ImndUnS ~e concentrates and lo~es h~m atockpi/es, Drest/¢ reductions in output since 1989 have reduced emissions horn beth plants more than Froportinnately became co~'.cen~tes are handled moR ca~fulJy and dust control systems are not expected to oper- ate far beyond their design capacity. However, it is probable that neither plant is economical/)' viable in the IonS run at cur~nt levels of o.qput, unless the size o[ their work [orce <L.'~ttcaIly cut, sInce they are operating at less than hal/the scale of equivalent plants in masher economies. The immedlat~ priori~es axe measures to deal with dust fi'om concen~ate recepHon, stockpiles and handling. At Copsa Mica, a simple system of water sprays to damp down the stockpiles---at a cost of less than US$100,000--would have a big effect, provided that the water drained horn the stc<kpl/es is properly I~'eated. Completion or installation Ot perimeter wars (or even complete enclosure) plus other measures to prevent spillase--c'osUnS Less than U55~' mtl. llon at each plant--would greatly m:luce the dispersion o| dust that has contaminated the areas around the plants. These should be "win-win" investments since lower concen- kate losses shoukt cover most or all of the costs involved. Similar "~ood housekeeping" measures could also reduce .other emissions to both air and water at a ve~ smaU cost. At Ptovdlv the dust coRnction system within the plant has been substantially upgraded in the last two yean with the in~tallation o~ new hoods, baghoose ll]ters and upsradinS of the old equipment. The photos management expect to be able to meet the new endsaion standards which came into effect in lanua~3,1993. Similar measuxes are t.he ~econd pd- salty at Copse/vlJca. A sttm oir US$2 million should be su/fl- dent to repair and modernize exist:inS controls ;rod to in~taU • dditional hoods a~d filters. The sul/mic acid plants at both Plovdlv and Copse Mica are in a bad state of re,pair. Most o~ the sul~r dioxide pro- dured in the sinterinS and roasting operations and in the blast hu'~ace is endtted to the air rather than being recov- ered. New add plants could not be ~nstifird e:onomJcal/y, but repa~ and upsredinS to pnxess more o~ the sinter plants SaS~ could reduce 502 emL~io~ substantial/),. The co~t would be o~ the order st U5S3-4 mi/lion ~or Copse Mica and U5,$6-8/or Plovdlv, part of which could be deDayed by the hiSSer sulku'ic add yield kom the plant~. excesses of both aoate and cl~onic rtsp~ratory disease as well as a variety of heart and other conditions. The darn- age done by partlcuhtes may be exacerbated by relatively high ambient levels of sulF~tr dioxide and carbon monox- ide. Eliminating the poUution from steel plants should allevlate many of these heath conditions, even for long- 0"1 0 0 CO BATCo document for Mayo Clinic 27 March 02
Page 68: 39000936
Box 4.3 Cost-effective ways to control emission-, from transportation mvaces Cmt.~Yective ms••urea to con•sol lead emissions may Include (a) •axleS fuels d.lflerentl~y ~conl~S to lead c~nt~nt, and (b) ~ mulating the leaded grade of motor fuel. Vehicles tabS • leaded ~'•de of gasoline would not be using cataly~c cony•trent, and thus have much higher lead emissions than the (mostly catalyst-equipped) veh/cles using unleaded g~ollne. Since th~ vehicle stock in CEE is, on average, old (in Hungary. 42% of" passenger cas~ ~re over I0 yea.,~ old, and 62% are over 7 ye,~s old), poorly main- tained, and includes • high proportion of" can with }dgidy polluting two-4troke engines (in Hungary, two-stroke engines compr~e nearly one-third of the vehicle fleet), ccst..eHective strategies may involve tars•tins the~ vehk:les. Pussibl• u'tt~urm n'~y include an ownership t~x which rises as the vehicle ages and an ownership t~x on vehicles with two-stroke engines. Alas'natively, govern- meets may offer subsidies for vehicle scrappaze or incentives (such as tax breaks) for the tcquisit~on ~ use of "clean" car~. ~t, cause o/r their intensive use, t~e amount of pollution emitted by bus~, trucks, and taxis is very ldgh In relation to their propor- tion in the vehicle fleet. Therefore focusing on h/sh-use vehicles may be • cost-effect/v• approach Eor many urban areas. A recent study comparing m0bi/e sources en~s~on .control options/or Budapest concluded that the least expensive way to m:luce mc~ile ~ pollution is to replace standard diesel bus eng~ea with "dean" engines (wl~ch are also a~re f'~e] efficient ~ stm~dard engines). Another study showed that s'~ro~t~ng high-use vehicles *uch as trucks to operate oo "dean" fuels such as Hqukl petro- l•era gas or compressed natural gas may be cost-effective for some dries. Finally, it m,~y be cost-effective to target taxis fur emL~/on standing sufferers. T~e benefit of' investing in better envi- ronmental controls ~¢or steel p]ant~ are typ|calJy large because of the size of the l~pulation ah~ected and the health gains that c~n be achieved ~n a reasonable period of t~me. COAL BI.~N~G IN HOUSEHOLDS AND SI~,[.I. ~31L~S. Although the volume of coal burnt in powe~ ~lations ~'~d large industrial plants is generally several t~nes •.hat used in households and small scale boile~, it is the latter which ~ responsible for a larse portion of the local concen~ra- Box 4.4 EnvL-onmental invests•eels tn the iron and steel industry ' The main sources of pa~culate cud•sloes horn bon and steel plants tm n~terLtts l~nd~ng and storage, coke ovens;-the •inter p~ant, blast furnaces a~nd steel converters. Most pL~nis have reasonable facilities for primary gas coLlection and ciea.ning for coke ovens, |inter plant~, blur furnaces and oxygen converters, espy where the exhaust gases ~ used to fuel other stages of the operation. Thus, attention must focus on secondary collection of fugitive emLssions including those flora char]~ng and dischar~g steel con- ratters. These emissinns may be high because of peor maintenance or careless opera ting pracHces in the Past and de•ling with them wiLl involve the install•Hoe of ventilation h0¢ds, fans and filters or precipitators whose costs will be higldy pisnt.4peciflc. At Krivoi Rog in Ukraine dust generated by the nearby iron ore beneficiatlon/pelle~tton plant is the most serious env~mnmen- ht problem, wl~le better arrangements for dust suppression •re also ~Ffired at Kosice in $1ovakla. Wat~ sprays, l:,art:lai enclosun., of cooveyor belts and other simple measures can reduce dust emissions, especially that generated by handling fine ores in dry and windy weather. The investment cost would amount to US$1-2 per tonne of steel-making capacity or up to US$25 mRlJon at Krivo| Rog and up to USSI0 raison at Kosice. At Koslce, all four units of the •inter plant have cycfones, wh~e two have abo had elect~cetatic preclpltatoro fitted to the •inter breaker and screening areas but n~ to the •inter furnace. As • ~m.h, th• era/salons f'rom the stacks at Kos[ce are dirty, ted wiLl almost certainly contain relatively large amounts of fine ion oxide dust. The solution to the problem, which is ex'per~ive, wtlJ involva changes in operating practice to improve the sinter quality, and the replacement of the fsnit~on and filtration systems. The total cost of these measures applied to two of. the units (two are expecled to be closedl is es~ted at US$12-18 million. The •inter pisnt at l~ivoi Rog has a very bad dust problem, partly because It uses low quality waste and sludge ~vm the ion be~eficlat~on pisnt. A combination of better housekeepins~ lusts•Is•ion of fans with ~ffic~ent capacity to capture and dean waste •as prior to ~tack alL•charge and the use either of iron ore peUet~ or. of higher grade fines could achieve isrge reduct'~ons in emls~ous. The plant management would like to invest in • new sinte~ prop•rat:hie plant, but more l/m/ted investment of up to US,$50 m/Ilion to/reprove the exflt~ng unit would probably be ~u.st~ied. Conrro~ng paniculate releases ~'rom coking ovens is largely a matter of soed operation and maintenance. ~or example, •d~her- ence to a reg~Jar charging and di.scharg~ g schedu.le and •flee•lye control of oven heat:inS can assist in minimizing brickwork dam. age and hence gas leakage. Where plants have been poorly o~erated and maintained, signi/]cant repairs may be needed to affect a m:luc'don in emissions. The coke ovens at Kmlce and at Krivol Rog display signs o[ age, mhtae and the need for urgent repair. Most of the doors were leaking and there was a constant haze emanating from the top of the ovens. Det~ed stod/ea of the coke ovens would be needed to determine the precise measures needed to seduce the emission leveh but replacement or ms)or rehabil- itation o~r many of the coke batteries may be necessary in th• medium term. ThB would be e~q~n~tve with • c~t of UC~100 million or more for go•ice. Improvement of pr~ l~trticuL~te cont~ola plus Installation of ~,condtry htme col/ertion and ciean£nS/or b~ic oxy~n con- vertm ta exist~g basic oxygen conve~ers may cost up to US$I0 per tonne of steel.retiring capacity. For exan~ple, th• ele<tn~tatic l~'ecipitator on one o| the Basic Oxygen System {]~)S) units at Kosice was inefft, ct:Ive--4.he stack was e~it~ng • th.[ck plume which deposited red dust ~'~md the sur~undinS ama--m~d may need ~0aJ.r or rt~pincement at • ~ of up to US$a million. It is tudikely to be worth invest~g sisni6ctnt sums in open hearth plants whine eronom.tc ~ should be .acy limit~:l. C~ BATCo document for Mayo Clinic 27 March 02
Page 69: 39000936
tio~ of pazticoJates and sulfox dioxide Ln the majority the most polluted urban area~ in Central and Eastezn Europe. In Poland |t has been estianated that the ~on l~ving in those urban ,.-~zm's wont ~'ected by l~rtic- u.lates amounts to about 8 mi.~on people out of an urban population of 24 million. The prospective health benefits to such p~ople of remediating the~e emission~ are sh'nilar to those described previously for people living near iron and steel plants. RURAL WASTE WATER TREATMENT. A program of rural waste water t~eat~ent wMch eff~vdy ~uc~ ~i~ ~te I~ ~ s~ow we~ and o~e~ ~g wat~ ~ sh~d e~te ~e pmbI~ of m~~- ~ ~ n~, wM~ R ~d~p~d of ~y co~ ~ C~ ~d ~tem ~g ~ ~e concen~o~ ~volv~ a h~e n~ of ~ m~s~ d~i~ to ~u~ d~ of ~d to ~ t~t ~dwater • e ~1~ d~ of h~ m~ ~volve a ~e ~m~nent sion and pubic ~u~fion ~ we~ ~ ~c ~ ar s~ple syste~ to co~ and ~t w~tewat~ ~ ~er ~g~ ~d s~ to~, ~e ~r ~e ~ p~ I~hUon fo~ow~ up by e~ve ment to e~ ~t ~e d~i~, co~on and o~on ~ ~ not a~, ~c ~ ~t ~u~ for ~dwater ~u~o~ A sho~ t~ p~ to ~ce ~he ~dde~ of m~- ~oglob~ ~ong ~ shoed ~nc~te on ~ pubic ~u~on and ~e pin.ion of for ~ at ~ S~ b~st-f~g ~ ~ely ~u~ ~s~ to water.me ~at~ ~o~fion shoed ~ ~dud~ ~ ~y h~lth ~u~fion ~ge ~g ~ntemp~t~. H~l~ p~ion of ~l~ w~t~ smo~t to a s~y pa~five approach, but they" axe necessary interim steps because other measuxes to m:luce levels of n~tr~tes will talw a con- slderable period to have an impact on exposure levels. Once the populaHon is being provided with bette~ protec- flon from exLstins problems, the ~ of public policy shmdd turn to z~iu~ns the flow of n/trates into 8round- water, especially from intensive animal husbandry and improperly maintained and/or Io<zted rural septic tanks. The immediate pHority for public Lnvestment should be to ez~x~ that the manu~ ~ feed]ot~, dairy and pig IdgMy concentrated eHluent Ls not allowed to ~,p into the ground and Ls no~ dLschaxged into nei~hborlng sU'eams or Rive~. Quite alert ~z~m the contribution such act~v/t~es make to levels ol- nRxates in gxoundwater0 they can have a devastaling impact on Hver qua]Ry and aquatic l~e ff the untreated ]/quora ~rom manure heaps a~ simply piped into enterprises, it may be sensible to invest in col]ec~ve treat- ment and disposal arrangements w/th effluent l~-,ing Iz-,ms- ported to the cenl~a] faci/Ry. Projects which provide 6nance ~nd technical assistance l-or such faciZi~ies may be exce~lent canal/dates ~or support ~rom the donor <~mmurdty. Other Stzateg/c Conzider=llon~ DEAI,~G WITH OLD II~DUST'R[AL PLANTS. Whether to invest in poDutlon cont~rol in ],z~e old indus~Lal plants depends on tradeo~s between social benefits and ~o- nomic ~actors. The choices are (I) to close down such pLsn~s as rapidly as possible on both economic and envi- ronmental gxounds; (2) to perndt them to continue to opexate l'or a ]/mited period as in the past; and (3) to perz~t them to conl~nue to operate provided that environmentM im]~rovementa aze implemented, in'a considez~ble number o~ cases modest environmental investments could ~enerate a good return ,,vlt~Ln 2 to 3 yeaz~. In such cases, there is no b~[s to allow them to operate zs in the past. I~ the govern. ment (or the enterprise) /s un,,viJ]ing to ~mnce modest improvements, then thls amounts to a decision that the social benefits ol- keeping the p]ant open do not outweigh Box 4.S Investments to control emlssion~ from coal buraJ.nS For large bum it b ~, at m~t ~, ~ ~ ~c ~to~ or o~ d~t ~t~ ~ e~ ~ ~t ~ mo~ ~ ~ ~ we~ ~ ~e ~flvdX M~ ~n veI~. By ~n~ ~e ~o~ ~ ~ ~ on e s~ ~e ~ ~ of~ ~ ~, s~ ~ ~d ~ ~, ~d s~ ~ hea~S ~. ~ d~ not m~ ~t ~io~ ~m ~w~ s~o~ ~ ~ ~ ~ ~ ~ n~, ~t ~ ~t ~e ~lu~on b lu~n ~n~i ~C BATCo document for Mayo Clinic 27 March 02
Page 70: 39000936
the cost~, •nd the p~nt should be do~. L~ other won:is, • e s~t~c ~oi~ ~ ~n (1) ~d (3) a~ve. ~ m~t ~pmvemen~ ~ not ~ble or n~ ~ eff~ive, ~en ~e gove~ent shoed ~ an a~ lute ~ te~ for ~e ~n~u~ o~nfion of ~e p~t ~der ~oice (2) a~ve. ~ s~n~Hy l~s t~n the ~y~ ~ for ~t~ end- m~ental ~v~en~. ~s app~ch pm~d~ ~r ~de~ for a~on w~ch allow gove~ents to ~e ~ o~ ~oic~ a~ut the ~ad~ ~n ~e ~ c~ of ~employ- m~t and of con~n~g en~en~] da~ge. It g~, ~her, thal all public ente~ shpuld ~ sub~ to a ~adual fighte~g of en~en~] ~ndifio~ for ~n~u~ o~fion ~der w~ ~g~ m ~ld ac~un~ble for ~g p~ive ~pmv~en~ en~o~en~] ~do~n~. o~y one pan of ~e sto~ ~d ~y not ~ ~ ~e m~ ~ny of w~ pay for th~Iv~ ~ugh ~u~ age and ~uc~ e~sio~. For e~ple, pm~rly ~g plant ~d ~uipment, ~g ~ ~t ~n- men~l ~n~ o~rate acco~g to s~fion, ~d d~g p~mpt]y ~th I~ ~d sp~ ~ go ~ to ~u~ p~t e~s~o~. ~ ~n ~ ~ a ~H~ of ~ent to ~d p~de ~ ac~e~g a ~er ~en~ ~. ~, ~I ~t s~Hc st~ su~ ~ ~bfi~g ~ a~ev~ merit of phn~ or work ~u~ w~ ~e ~t ~- ~en~I ~pmvemen~ ~ p~u~ s~gly ~e ~ne~. It fo~ows ~t ~v~enm m~t ~ ~o~ by ~ndi~ on ~gem~t ~d work~ other p~ to ~ ~ b~g ~e ~t ~ible Co~u~ health p~mo~on prove to ~ ~nefi~]. Breast f~g men~on~ as a pa~afive for methemoglob~e~, and prevalence of breast f~ ~y ~ in~ by ~u- ~ or c~c ~d ef~o~s to promote it. ~e~o~, comm~fi~ con~am~t~ by lead ~ ~ ongo~g effo~s to ~move ~gh-lead dust ~m hom~ ~d ~uce con~ ~th con~t~ ~, ~en ~ ~ion ~u~ a~ ~n~oH~. ~e lo~er ~y ~ home vac- uu~g pro~ams and the ~er ~y ~vo]ve to ~pmve ~ass-~ver or to cover ~n~t~ new, uncon~t~ ~H. ~ the ~s~ whe~, su~ e~o~ a~ ~t o~a~ l~Hy. ~e Need for Remedia~on~ented He~ ~e ~te t~t of eff~ven~s of ~e ~v~ ~d ~ d~ a~ve ~ ~ ~fl~ • e foHo~g qu~fio~: • Have ambient leveh of ex~s~ ~ dio~de ~nd water,me ~Uat~ ~n ~uc~ as a ~sult of these ~H~ and ~v~ents? • Has morbidi~ ~t~ to th~ ~ ~n ~u~ at the ~me ~e? BATCo document for Mayo Clinic 27 March 02
Page 71: 39000936
made for recn~tins control ch~dten born ~ who ~ ~ to ~ond-~d ~o~. ~ ad~on to ~mple s~s, it ~ ~m eme~ ~m ~i~ for ~ ~n~ iW, ~u~ely ~t~t, it shoed • e av~se ~u~t l~el d~ Su~ ~on-~ ~ dam syste~ w~ .we~ a ~five s~n~ of te~ ~ heath ~ NITRATES IN DRINKING WATER. "l'here will need to be ~wo [orms o[ outcome evaluation in commu.~les wh~'e waterborne hi.ares are a~sociated with endemlc me~h~- moglobinem~ia. The first would simply involve evidence o[ decl~nes in morbidity and morta~t~ ~m methemog~- binc-mia as a ~sult oi short term interventions which did not affect the nit, ate content of local drinkin~ water (Le. public education and provision of bottled water). ~ would involve a rigorous case definition of methemog|o- binemia-related morbidity wldch could be determ~ed/n an inexpensive and uablas<~l hsh/on by rur~l be~Ith care pra~tioners and ~ra.n~n~ted in standardized ~orm to loc~l public health au~horitles. The second [orm of evaluat/on would involve evldenc~ tl~t using • ~pply w~ ~ ~ no ~ of ~d~ m~ m~ob~. ~ w~ ~volve ~8 wom~ w~ ad~ to ~ ~ I~ ply a~ M~t ~ war,me ~ lev~ w~d n~ m ~ sv~ble at ~, ~b~c heal~ p~n~ and ac~ to s~ epide~ lo~c ~el. ~e ~ ~or a co~ ~ml ~ide~ol~ ~ not b~ ~l~y on ~e n~ m ~ ~t ~v~. ~ ~ a~ a n~ m ~mpl~e ~sh ~ e~d~olo~c ~mdim ~de vad~ of ~en~] heal~ conce~ t~t ~d~ately evaI~t~ ~t p~nt and to d~e]op and ~in~ ~ ~te~ to d~ paHe~ o~ morbidi~ ~d mo~ ~ ~e ~ w~ ~ght ~ve ~ en~n- men~ Note I. "~e prolx~'d threshold Ls b~szd on the It~ndard WHO ~de~e. w~ch ~ Iden~ to ~e US ~d~m for the qu~W ol pub~ ~8 w~¢ec ~e ~hold ~ows a co~ld~able ~a~ wo~d ~vent ~t ~ ~ of ~ ~e EC ~g wat~ s~ S~ ~t ni~at~ ~ho~d not ~ ~ mg/I ~ N~ w~ ~ ~v~ent to 11 BATCo document for Mayo Clinic 27 March 02
Page 72: 39000936
Annexes BATCo document for Mayo Clinic 27 March 02
Page 73: 39000936
Annex One Separating Fact from Fiction: Collecting and Evaluating Environmental Health Information This ~ection provides a description of the methods which were reed to collect and evaluate available e~idemioingi- cal and exposure information in co~mtries of Cen~] and Eastern Europe, The knowledge base Is largely composed of studies done under conditions which we~.e not technl- cally or ideologically favorable to epidem/ologicinvestiga. As much as po~ible, the idios)mcr~ies of each court- try's investigation have been preserved in the text so that the readers can ~dge for them.selves the sorts of limit•- tions under which data col]ec~on took place. Methods of Data Collect/on The principal method of data collection for this invest/g•. fion was a form of "epidemiologic tourism" th,q~gh Cen- tral and Eastern Em'ope. From the autumn of 1989 to the summer of I~92, mu~t~-di.s~plinary m/.~ions of environ- mental special/sis from the World Bank visited ten coun- trie~ in the re~ion: Poland, Hunsary, Czechoslovakia, garia, Roman•, LaW/Zo Lithuania, Estonia, Belarns, tnd Ukraine. The role of the envlmnmental epidemiologist on the team was to oollect all /nformat/on possible which might identify human health effects from env~.mnmental pollution. We collected Lrfformat/on personally in eis~xt of these coyotes tnd received reports from colleaS~es who visited two others fBelar~s and Uknine). The oountry visits were a chalJm~ge. They wex'e not long. last~g up to three weeks in large, pol~doos court- tries llke Poland a~d only a week in each of the smaller Be]tic Co~n~-ies. At the ~ut~q of each v~it a contact in the leading government agency respons~le f~r envimnmen- ta] health was assi~med to me, a~d a skeleton plan for meetings and site visits Fn~pased on the basis of prelim/- nary World l~nk investigations. Our cha~.lengo wa~ to q~ickly overcome the language bar~ler, estab~h • he•son- able level of trust, and identi~y the key ag~ and invea- t/gators who actually knew something about hum~.n hetlth and the env'i~nment. When th~ process was ~cceuhd, we ended up slx, nd~ng our time col/ecting t~e highest quality infom,~fion avaLlable nther than wasting it Inconclu.sive, non-technical dbcusslon& A typlml successful ~eesion wou~d be • ~eries of one- on-one di.~u~iom with front-line investigators from an agency m" institute who would explain their ~]c~ta to me and give me the opportunity to ask questions criti- ctlly appraising it. Usually, the outcome of such sessions was s/reply our l~ndwrRten notes. But whenever possible we •coep~ed their written documentation, Usuagy the investigators were willing to help h'ans~ate key tables, ~g- rues zmd abslzacts which made the documenl~ u~ble. Much of our time was taken up trying to confirm rumors and sweeping statement~ about the state of envi. ronment and health in • particular counlry. Often, it turned out that supporting data which were thought to exist, in fact did not, or else showed the opposite of w.hat it was claimed to show. Fm:luently, studies which were being relied upon at the policy level turned out to be ~ flawed a~ to contain no usable in/ormation at all. On the other hand we did find some reasonably valid and ~ellable information in every country we visited. O/ten it had been 8crier•ted in agendes and by investigators not sought out in environmental policy development. The F:oximate outcome of our visit,: was a eeries of corm- rational health literature. We we~ very ~elective in what we included, dJscantin8 virtually all lr~rmation which lacked included to explain why we disbelieved a o:nnmonly-hemt human health concerto. The Structure of EnrLronmental Health Dat~ Collection in Central and Eastern Europe This sec~on describes the •~v/tiet of the prindp,d agen- des responsible for collection of env/mnment=l health data in ~everal of the coun~es of CentraJ and Eastern Europe. The ~-v~ew does not include a/l countries because 61 0 O0 BATCo document for Mayo Clinic 27 March 02
Page 74: 39000936
in a s~ictly l~ragel way. The ~ttem~ be~e is to highllgh~ dJfferex~t 1~sues by referenc~ to examples which occurred in l~r~icular counties, but wMch are no~ con- 6nad to During ou~ visits, it was i~porta.~ to repeatedly emphas~e the fa~t that the data mo~ pertinent to hunmn health was not necessarily the data of ~eatest inte~st to ~in~es of Environment. For ~tance, ambient ~r qual- ity da= is more relevant ~ endsslon data for ass~in~ hum.~n health ris~, whL~e the rev~e may be u'ue for cha~ =ct~rlzin~ l:~tia,.~ ~ of poHu~o,. Ministries of Enrichment in Centnd and Eastern Europe were ~ene~ all), most concerned with em.L~ion data, wldle lnsUtutes Hy~ene, under the ansplces of Mirages of Hea]th, o~ten had more extem|ve information on ambient air quall~ Moreover, the principal agendes o~ten had only = minority of the relevant information at thdr dLsFosaL Some~nes allied =sencies, such ea a ~ticularly a~ve cancer ~ ~, would have information yieldinS the most useful insishts. Activities o~ a selected sample o~ these allied a~ende~ xrt highlighted In the section following ~ one. Po~=n~--Until the po~t~cal c~es ~ 1989, the two most important a~encles in the environmental he~l. th field had been the sanJ~ry epidemJologT staUons, which are sul~rised by a cent:raI Institute of Ry~ene of ~e ~ ~ of Health, and the State EnvLron~enta! L'-ml:~'torate of the ~is~'y of Env~nment~l Protection and ~atu~ Re~uxces, which is closely assodated with the L'~titote for Envizonmental Protection, In general the a~dv~ties of the sanitaz'y epidemJolo~), stations (herein known as san-epi stations) are ILke ,aunerican health departments, but in re~ons with cant env~nmental pollution pmblem~ they have a strong envimnmentaJ health component to their act~viLies. Tids is focused on the hunch experience of exposure to envLmn- mental pollution, They are concerned with =unbient air qua~ty, drinking water quality, and fo(xi contamination. They aL~ am responsible for mo~toring ab" quality in the workplace. In conLrast, the envtmnmenta| inspectorate oriented rowan:Is the control of sources of ex3x~sure. Thus, theJ.r mordtorJng acidities generagy concern pollution em~ion rates ~mm seu~es of ex]:~su~ and not ambient conditior,~. In theory, this is an e~t~mely rational ~ tion to make, but in practice, there has been a ~mat deal overlap in the agendm' activities. For example, in zones "speclaJ en,Hronmenta! ~rote,~on," which am nationally- desi~mated because of theb" particular ecological canoe, the env£mnmental inspectorate does studies of conta.mination. The~e studies, by desisn, sample food in geol~raphic duster at its sot=me. The san-eFi stattous sam- ple the "foed basket" as it is found in the mazket wldch repre~nts the food supply as t= is daLivez~l to the people rather than as it ]eaves a re~Jon which ntl~t be polluted. Both the san-~ stations and the envbonmen~ torate have coL~e~ed ambient air pollution data in the zones of special protection, but san-epi has had a much mort extensive network o! monitoring stationa and been able to eample a large~ number of substances. Their rou- tine measmement~ L"~clude dust sedLmentation, aid~ome paniculate concentrations, sulfur dioxide, and oxides of nim~en, while carbon monoxide, phenols, formaldehyde, heavy metals, and be~zo(a)pyrene art sampled on a nearly ~6ne l~s~s. ,%~-~i l~s 49 dist~c~ s~tions vHth 32g sub- sidJa~y ~eld stations and approxim=tely 560 points around the =ountry where routine e~vizonmenta] data are col- lected. The Institute of Hygiene serves as a warehouse for ~ ~ta produced by ~e sardtary el~demlolog7 stations a~nd aL~o ~II emJ.ss[on data generated by the Insti~te for Run&ary~Unll,ke in Poland, it has been dif~colt to get an adequ=te overview of the institutional linkages dealing with the public health ~spects of envi.ronmental polJution In Hungary. From interviews ~d c~scussions ~n Budapest, it was dear that the Na6onal I.ns6tute of Hygiene, which e~is u~der the auspices of the Ministry of Health, was the principle agency responsible doing reseam,.h into the health status of Hungarians. Under ils =uspices come the monitoring of 79 settlements for sulfur dioxide, oxides of rdtmgen, and soot, and 99 settlements for sedimentin~ dust. Also, 6ve disease reSistrles are maintained by insti- tutes witl~n the NIH, which relate to mortality, cancer, congenital abnormalities, c]u'o~c, pulmonary diseases, and acute respb'atory morbidity among children. "Dtere seems to be g~eat va~iaEon L~ the degree to which the different institutes of the N~ actually pursue envLmn- me~t~l causes of iLUhealth. For instance, the Center for Conge~tal Anomaly Control has a very active pro~am of en','Lronmental surveillance for anomalies related to work- place and environmental conditions. On the other hand, the Nation=l Instltute of Oncolog7 has made |ew effo~-~s in the ~ of occupational and environmental causation. Thertfore, there is no adequate su~veil~ance system for occupational cancer or any regional cancer mapping as would be common in Western Europe or North America. In the reg-ionsl centers, the sanitm-y epldemiolob,7 stao tions have resFonslbRity for the public health aspects of environmental exposmes. However, the degree to wbic~ this mandate Is ca.rried out seems to vary ~.atly from ~,~on to region. In Miskolc, an area with si~mificant envi. mnmental concerns, the sen-epl station seemed to be actively Involved in data col]e,:tion, ~sea.rch, and the pub- lic heath response to local L~sues, o~ten in cogaborat~on with the cent~ institutes in Budapest. In other parts of the country the sa~-epl stations seemed less relevant. There was also a widespread sense of dis~-ust throughout the counh-y regardin~ data wldch were produced by the Insti- tutes in Budapest. In Misko[c, whe~ the san-epl station was active, there was dish'ust ex'pre~ about the quality and veracity of the data which the), were producing. This dLstrush and ~ometimes rivalry, extended into inter-insei- bational relaLionships as well. Pot instance, ia Poland Institute of Occupational Medicine and the Institute of Hygiene cooperated clo~y with the san-epi sta~ons in coIJecting and eva[uati.n~ occupational expesu~e data. In Hunga.r),, it would appear t.~t the Inst~te of Occupa- tional He,dth has, u~til recently, been cut off f~om the agencies which deal with env~nment~ healt~ condl- BATCo document for Mayo Clinic 27 March 02
Page 75: 39000936
ttons. The diIficult~es here ~;o a~ far ~ to in~ude an epi- sode In which quality cont~l I~.mplea sent to Hungary from abroad to standaxdlze the work of vasious labor~t~- riea ot~the Na~nal Institute of Hygiene were taken by one institute (not the one which ordered them) and not passed on to others. ~/tmc~a--Even before dissolution of the federa- tion. the principal agendas respons~le for investigating human health aslx~ts of envL-onmental pollution in Czechoslovakia were separate for the Czech and $lovak Republics. In the Czech Republic the Institute of Hygiene and Epidemio]ogy was the lead agency, serving as the cen- wal re~ouroe for the san-epi stations, much as the Institute of Hygiene did in Poland. The san-epi 5tat/ons were orga- n/zed by t~-gion, and x~,ions with many envkonmental pollution pmblenxs, such as northern and central Bohemia, had active environmental health investigat/on programs of their own. in the Czech Republic it was easier than any- where else to find individuzb in academia and the Central Statistical agencies who were making useful contributions in the field of environmental health. Unfortunately, some of these efforts were going on unnoticed by the L'~titute of Hygiene and Epidemiolog>.'. In the Slovak Republic, the lead agency for our purposes seemed to be the Research Institute of Preventive Medicine. .A~ its name suggests, th~ agency had a much st~onge~ "orl- [~nal~ research role but • weaker "service" ~ role than the Institute of Hygiene and Epidemiology. Thus, it was difficult to obtain hum them routine monitoring data and othe~ information of unambiguous relevance to public health. We were able to obtain some ~ infonnaHan on contan~inated land and food pollution from the Institute of F'o<xi. In addition, the Slovakian Cancer Re~stry was the first of several we visited in the ~gion which had case fund- inS systems of international caliber. Bufgar~--By the time we reached Bulgaria, we were • ble to anticipate the agent:leg which were taking the lead in investigating the hunutn health as]x, cts of environmen- tal pollution. The Institute of Hygiene and (kcupational ~ served as the ceniyal resource for the db~ct hygiene and epidemiolof:/- stations, which are mugldy analogous to san-epi stations elsewhere in the ~,ion. The district hygiene and eptden,,ioloT,." stations have n'~ponsi- btllty for collecting aJ, r, w•ter, and soil data relevant to industrial exposures as wel~ as has~g a role in ir~$ industrial work places and in food hygiene. They were organized on a regional basis •ccordlnS to 28 districts which map neatly onto the 9 lm~er regions that are used for other •dm~O.strative ~ in the M/ntstry of Health system. Unfortunately the 28 health d/sU-lcts not the same as the 16 MJ_n~b'y of Environment districts, making integration of Ministry of Env/~nmene and ~ try of Health data somewhat awkward. The Institute of Hygiene and Occupational Diseases ha~ 3 broad functions in support of the work of the hygiene and epidan~iology station: to conduct studies into problems requ/_dng special ex~; to estab- lish exposur~ standards and norms; and to develop Iabo- ratory methods. The Institute also has • role in collecting and organizing data hum the 28 stations. The general corn- putor center of the Bulgarian Academy of Medicine is hmnd on the same premises ~ the Institute of Hygiene and Occupational Diseases. It i~ responsible for the main- tzmnce of 16 clisea~ regRh-ies, ~ on routinely colo lacteal data throughout the health care system of Bulgaria. This core resource supports regional centers for informa- tion technology in each ot~ the 28 dts~ct~ of Bulgaria. The scherzi flow of information is from the d~trict~ to the cen- te~o o~tan with increasingly summm-lz~ and di~t~dled information •vailable by the time it reaches Sofia. The Minist=,y of Health role in ak qnafity is confined to monitoring of ambient levels, not contxolling emissions per ~e. The Min~txy maintains a network of 89 stations for sample-taking in strategic locations around the county/. Data hum the 8~ stations a~ collected under the auspices of the hygiene stations and ~orwarded to the Institute of Hygiene and Occupational Diseases. The data ~'e subse- quently se~t on to the Min~txy of Environment for c~tiun in their quarterly reports. The Ministry of Environ. ment aho recelv~ data hum the Institute of Metoon31ogy and Hydrology, which has several ambient air monitoring stations, as well as hum its own network of 30 stations around the country. The g~neral impre~ion aeated was that the Ministry Health and ~ of En~t did not have axrfe~n in the a~a of monito~S ambient air q~llty or of the lv~'dstry of Envim~t were in the aret of air pollu- tion due to en~.~io~ hum power ~ation~ and the l:neblen~ ~ coal burning in hou.~e~. By contr~t, the MinLqry of Health wa~ particularly concerned with hot ~ where multiple air, me ~ of the i~l~dation occurred as a resuk of ~ton/a--Despite its sn~J size Estonia had a rather elaborate and uncoordinated network of agendas inter- ested In the ~ubllc health impact of environmental pollu- tion. The,~e agendas include ~ san-epl stations, the tute of Preventive Medicine, the Institute of Experimental and Clinical Medicine, the Institute of Hydrometeorology, the Min~try of Environment, and the local environmental The Min~try of Envtronmen~ls the lead agency in envi- ronmental protec~on in Estonia. It~ current priorities are to protect the forests; to find les~ poliut'~ng ways to burn oil shale so that Estonia can maint,dn ene~x seLf..sufficiency; to decrease em~sions hum the chemical indust~'ies which ~ otl shale; to upgrade the Eesti Tsement plant, which is • major sousce of dust l:~3liution; to Ul~,r•de wastewater treat=~ent throughout the countxy to comply with the tic Sea convention; and to decrease SO2 emi~ions by 30 pe~,ent and NOx emi.~ions bX 70 percent in compliance with International conventions. At pn~ent, the Mird~try is in • retatively weak position to fulfill its leading role in the envi~mnental field..t~tde hum being stxapped for cask, the Min~txy does not have tt~ own air and w,,ter me~urement capabilities and has had no control of the anvin~nmental monitoring In the ~L The v~t majority of air and w•ter quality mon- itoring is done by the L.~'dtute of Hydrometeorology, which has operatod accov:UnS to ~ ~ampllnS strategy ~d BATCo document for Mayo Clinic 27 March 02
Page 76: 39000936
down by Moscow authorities 15-20 years ago and r~t changed substantially thereat~-.Thb has meant that the~ has been l~ttle input from the Ministry of Environment, l~cal env~'~nment~l commi~tea~ or Mir~t~y of Health regardin~ what, when, and whe~ to monitor. In the n~ior~ whe~ the~ a~ ~ign~c~'~t eavironmen- t~J h~lth problems, such as Nerve and Kohtla-Jarve In the northeast, the san-~,pi stations have bee~ active in the BekL For instance, In Nerve the ~an-epi station has lx~ttcipated In large-scale health studJes of pollution and health, col- lacted some air and drtrddng water quality data, and h~ ke~t t~ck of occupationa] health problems. The head of the san-epi station works closely with the head of the local work ~or the environmental conu~ttee and the two agan- des carry out joint in~l:,ec~ons of industrial fadfities. Nonetheless, the ~lative weaknes~ of the san-epi station in environmental health was demonstrated by the fact that they had only one full.time staff member devoted to the field. The Lns~tute of l~evenfive Medic~e ~ operated under the attspicea of the Mhdstry of Health, and serves, in pa~, as a service research center for environmental health problems throughout the count,. It has a depart- me~t of hygiene w~th four subunit~: the labor~to~ of chil- dren's health protection, laboratory of atmospheric air tox- tcolog~ laboratory of food toxicology, and cheadcal sanitary laboratory, each of which carries out some Inves- tigatlon.s in "human ecology." Mo~t of the u~able environ- mental health i~ormation in the country has emerged from this institute, although, conversely, only a small tion ol what they produce t~nder the rubric of "human ecology" is helpf'ul for the purposes of ev;duating the impact of the chemical environment on huznan disease. In addition to facing problem~ which are similar to those in Central Europe (such as lack of computerization and upto*date analy'dcal equipment), the institute of ~ ventive Medicine has faced two other ~npo~nt obstacles to Its work, one of which is In the pro~ss of being solved while the other ls likely getHng worse. The fi~t problem is the long tradition of secrecy asso~- ated with birth and death statistics, and attendant con- cents about lX~r query conbol and ou~ght falsification of these data. Until last year, they were controlled by a cen- tral statistical agency in Mc~'ow which was ~latant to the T.z~titute°s special needs for vital statistics. In 1991 the data were taken over by Estonia, and there is confidence that the problems with secrecy and quality con~ol can now be ~lved. The ~'ond problem, a much morn intractable one, is t~'~t the Lnstitute of Preventive Medicine and the san-¢~t stations are seen as remnants of the old order by some Estonlans working in envL-omnenl'-d health, The main rea- son fo~ tl~ is that, until recently, there w~ no public health traintng Ln Estonian medical schools. All the Fublic health sl:~.-clalists were trained in Russian tn St.Fetersbm'g, and tended them,~ore to be ethnic Ru.~ians. ~ has led to an atmmphere In which Estonian-domLnated agencies, such as the Mh~try of Environment, are n~luctant to accept the professio~al ¢2eden~ls of public health trust their work orl~a les;itin'.~te role ~r them In ~vi~nmen~l health ~~ ~, ~e ~ of Heal~ ~ mo~ dolt ~ ~e fidd of ~en~l h~ ~ ~ ~t~ ~t ~ tO ~te ~e p~ ofiden~g ~d evalu- ton ~m ~e ~y-~ay a~ of ~b~c he~th ~ ffo~ S~g at ~e l~el o~ the ~t~ of Health ~te b~n~ ofau~oH~ div~m one ~r ~on ~d ~o~ for ~v~flSa~o~ It ~ ~e ~v~sa~ve w~ ~ ~l~t h~, ~e ~v~ga~ve b~ o/~e ~ of Health d~de on ~e ~o~fi~ for en~en~! and other pu~ • e ~ent of Hy~e or the Repub~n Hy~ene Cent~, w~ a~ the ~to~ agen~, on t~ cour- ts. ~e agen~ w~ch ~v~ ~on ~m the ~m- ~ ~ ~e ~te of Hy~ene, w~ ~ out mo~t of the ~en~l h~lth ~v~figa~o~ ~ the ~un~. ~ ~ con~ ~r a~, water, f~, and ~, ~e~ ~v~a~ve p~o~W ~ ~e he~th of ~p[e ~ the ~ a~ of ~Hut~ p~. ~ ~ve a~ to ~ly~c ~o~ ~d ~e ~ght m do en~en~l ~mp~ng. one y~r a~ ~ey kept the~ mottoes data ~parate, but now a~ ~nd~g it to the En~en~l P~t~on ~p~t ~or ~fion ~th data coH~ ~m other age~. From ~e to ~e they ~volve mu~l hy~ene ~te~ ~ ~e~ work, ~t ~e~ do not ask the ~to~ asen~ for ~put ~to w~t to ~v~te or how ~ ~v~gate it. ~ a muir, the I~fi~te of Hy~ene has o~y ~t~ one ~dy at the ~u~t of !~! autho~. ~ eff~, t~ system spli~ the ~to~ and ~v~safive m]~ w~ ~ ~t ~h~ Cen~l and ~te~ E~an ~un~ a~ fo~d ~ a s~gle agent. ~ ~ua~a, ~ ~ ~, the~ ~ no ~ of ~- m~t as ~ch, ~t a ~lly ~taff~ q~si-~ w~ch ~o~ a~ a ~ of pertinent and ~y to it. ~ Lith~ t~ agen~ ~ ~ ~e En~- m~en~ ~t~on ~p~ent, ~d i~ head en~ ex- ~ ~ ~fi~ the ~U~y ~ ~ of m~ ~ on ~e one ~d, and on the other, ~e ~t a ~ ~en~ ag~ as op~ to one ~ ~e ~en~l ~t~on ~pa~ent ~ to • e ~p~ a~ o/~on ~ the M~ H~ ~d ~~i ~t~o~ At ~e I~1 l~el ~m ~d n~ ~m to~ a ~Sh I~1 of ~t~on ~ ~e ~o ag~ and ~e~ ~n~ffv~ t~d~ to a~t. ~ sDt~. w~ was d~do~ ~ an ~- 0 (D BATCo document for Mayo Clinic 27 March 02
Page 77: 39000936
~ior~l envh'onment and murddpal hyl;/~ ~ ~ En~ea~l ~t~on ~i~ of ~e ~ ~y of ~e H~y Ci~m p~ Und~ ~ s~, ~o~m ~er t~ e~whe~ ~ ~e ~ ~d ~te ~e En~en~l ~t~on Co~, w~ch ~d~ ~e =~p[~ ot the ~~ pmt~ d~ ~ot ~ve ~ d~ voi~ ~ p~ent, ~t s~ at ~e ~uest of ~e ~pu6~. At ~e ~e of ~ ~t, ~@g was ~ k~i~on, and ~m~t w~ ~ ~s of ~g ~g ~mm= and ~g out ~d~. ~b~c health ~ a~ ~ an even ~t~ s~te • e ~g~ ~up a~empt ~ Aunt, I~2, ~e ~ ~b~c Heath w~ do~ad~ to a ~pa~t ~ ~ of ~l ~c~, ~r and h~l~. ~ ~t ~, w~ ~ ~ ~nS~ ~ ~e near ~, ~ ~ the ~a~eni am ~e RepubB=n C~ter of Hy~ene and Eplde~olo~, ~e ~ ~pa~o~ ~ C~ter o(the A=demy of M~i~e, ~e M~i~l ~fi~ B~au of ~l Sta~t[~, and the Re~b~n 1o~1 ~as~ ~pa~ent. ~e lml hy~ene ~nte~ ~ to ~e Re~$~can Center and, ~o, ~te lml ~pa~oml dB~se ~nte~ (w~ ~ pa~ of ~e A~demy of M~e s~), ~g th~ workplace ~on da~ u~ for d~8 and ~ ~- ~o~1 dBe~e. ~e pubffc heal~ system ~ ~ ~s ~ ~d~ively devot~ ~o ~o~ d~a~ con~I, at ~e ex~me of en~l h~lth ~ pa~r and ~ea~ con~ol ~ ffen~l. F~ of the I~1 m~i~l ~ve ~owl~ge and ~ ~ the ~] d~a~ par- ~di~, ~ ~ ~me d~ they ~ve go~en ~volv~ • e field ~ugh ex~u~ to ~paffoml h~l~ ~u~. ~, ~e~ we~ no smo~g da~ ~va~ble for ~ ¢not ~en di~ on ~r ~pim to~o ~I~), no p~d~t- ~, ~d a oncer ~ w~ was not y~ ~y ~ble ~r epid~oI~c p~. Two ~ ph~i~ (who we~ ~ m~ of G~n Pa~) ~d ~ ~ond~ for a ~ of mon~ to ~ a ~on of pubic h~ ~ w~h wo~d ~h~ 1~ effo~ ~ h~th ~d ~c ~ tonal. ~ pm~ ~- a~g ~u~h a B~ of Hy~e w~ ~d ~n ~y ~ par~t ~u~ ~e Naffo~ Con~l ~, a~ ~u~h ~e ~pa~t of H~ ~ ~e ~ent of Hmlth a n~ ~mte of H~ ~d ~b~c He~ wo~d ~ ~ for ~d~ff ~ as~m~ted w/th chrc~c ~nd msdronment~l i~ ~lp~ ~ Iden~ ~t ~um ~r ~vma~o~ ~ ~ ~e I~ ~s ~d ~y, to ~ out ~v~ga- ~ble to ~ve a~o~ ~e ~m o~ ~id~ol~ • e~o~, ~e ~mte o~ H~ ~o~ and ~b~c H~ wo~ ~ ~ndat~ to ~te ~ ~]~ da~ ~, work out ~m~t~on ~d id~ n~s for n~ ~ ~. ~ ~s the m~t ~g~y evolv~ p~ for e~ ~d ~tem E~. ~e C~t~ ~ ~ of ,~e hobble f~ of the H~n s~t~ ~ ~t physi- ~ ~ ~ by ~ to ~ p~ml on ~ p~t wo~en. ~pi~ of 95% of ~d ~e~ way ~ ~e ~ng~ml ~o~fion ~, w~ allows ~ide~ol~c ~ to g~ ~g p~n~, and m~i~ ~ndi~o~ of o~ ~ ~ ~r ~~I ~ of ~n~l ~e ~t~ ~ do~g ~e~ ~~ s~m ~ on ~ ~ one mon~ o~ n~m~o~ ~ a ~n~I ~y, ~ ~n~l ~to~. BATCo document for Mayo Clinic 27 March 02
Page 78: 39000936
Center s~ves both as a referral c~ter for the eJh~Ical t~at~ ment of individual cancer cases and a~ a site for data cob leetion and research ~.~arding risk factors for cancer. Th~ Nal~onil Ontological Center is the focus of a network of 13 regional cent,s. When n~,v cases of cancer a~ identified, local phystcla~.s are requh-ed to notify the regional centers, which ~ --~-,uiLly to the epidemlology depariznent at the National Oncofo~ica] Center, and to complete a cancer ~,vor~ng form which is the has;., of the reportin8 system. The information found on thh form could be of tremen- doua ose in surveillance for envin~nmen~ inftue~ces on cancez The reporting form differentiates between an intt~l fi~t on death eer~cate or autoi:~y. This is very useful information for validity and quality eontmt puri~os~. In ad~Uon, the form records sFed~¢ r~sidence in.formation which could ~llow detailed cancer mapping i/the tech~of osy were available. Also, there is information on occupa- tion, plac~ of work, marital status, and social gxoup: all important tn the analysis of cancers with multiple risk fac- tor. At present, efforts are being made to crnss ch~:k the mortality file with the cancer inctdenc~ fiJe for consistency. This is a very important step because iidormation on the d~ath certificates follows a separate Pel~r flow from the cancer inddence relx)rting system. In addition, it was claimed to me that 65% of individuals with a suspected diagn~is of cancer have an autopsy. ~ is a much higher rate than in North America and probably make; for more vafid data than some of that which goes into North Amer- L.l.mih~tiom in the Q~ality of the Available Information One of the principal impecUmen~s to unders~ncLln~ envi- n~nment-haalth relationshil~ in the Reg/on is the ~e~eraLly poor quality of data regardin$ exposures to envi~nmenl~l agents and, aLso, ti-.e a~ses,sment of human health outcomes. The Cenh-al and Eastern Em'opean Izadlfion of epide- miology is fi.m'dy rooted in inle~t~ons dLsea~ cont~:~l. ~n the West, the modern era of epidemiology was u~hered in by the landmark studies of dgarette ~moking and lung cancer in the 1950s in the United S~ates and Br/tain. The methods developed then were appl/ed to a w/~e variety of ¢.h~onie diseases and helped to ~ring about a p;volution in the con~bution of epidemiology and bio~tat~tio to the study" of health and health care. Durln~ the 196~, the n~- ormation of the ~ and Drug Act in the United $~ates brought pre~ure to bear to demomtr~te emp~ca~Uy the ~-cflveness of pre~:rlpt~on pb~'m~ceulicais. The rese,~-ch methods uzed to addre~ the~ concerns derived h~n the principles of ch~ronJc disease epidem~olog),. Post- graduate training in epidemiolog',/, blost:,tlstics, ~nd pub- Lie health ti~oughout the Eng~h speaking world has been odored tl~ way for the L~t two decades. It ~ proved to be ~n approach which is wel/suited to the study of c~nc'~o repr~uceve problems, or chronic r~p~tory dL~es wMch may be caused by or contributed to by occupatiorud It would appe~ t~t none of the Ce~tz-~l land Eistem count. The efforts of these individuals are quite notic~ able where they have occurred, but the lack of epldem/o- lo~c consdou~ne~ ~, seen acutely th~x~ughout the system. In genera], the assessment of human health outcomes has taken place w/thout due regard for el~den~olo~Ic princl- pies which help ~ the validity ofresuit~. In particular, few of the health studies from the region allow us to slmulo tancously asse~ the imptct of environment, ~estyle, and ~/actors on disease causation. The~ methedolo~¢ problems make It difficult to be unequivocal about what we believe to be true about environmental health in East- ern Europe. The han~ers to effective exposure assessment in the Reg/on are varied and complex^, relatin8 to poor equip- ment, slow turnarou.~d t~nes, agency rivalries, and non- existent quality conboi progranu. As a result, emharrasrr tng inconslstendes am often found when more than one agency has collected ex]x~ure data at the same place and time. These inconsistencies are often identified by e~ and not by the agendes con~ned. The complexity of the problems can best be understood by a few examples. Example I: Food Surrell/tnce in Bulgaria Food surveillanue i~ the country appear~ to be in a totally chaotic state. There are no less than 12 agen~es enSaged in u)me mon/toring and reb,~atory activity in relation to the domestic fo<x/supply. Nonetheless, very ~ittle useful Infor- mation has been retained on the nature and extent of food contamination. The agend~ do not coUaborate with one inother and do not use Min~try of Envi~wnment Informl- don on sou pollution as a guide to how and where to str~- tegically sample the food supply. Moreover, most of the Insly~cal pro<edu~s used to evaluate [ood have long turn-around Krnes, so that most food is sold before the results of analysis ire av:.illble. ThLs is a pa~cullrly important problem for sampBn$ under the auap[ces o~ the i~dn/stry of Health, since it is mostly confined to foods found at the market place ready for sale rather than at the farm gate. For reasons of ~ of •nalysiso vlrtuilly all agendes me~'u~ rdh'-ates in food. On, investi~tor circulated cucumber ~mple, blind, to several of laboratories and found variations in it~ measm,~ nRrate concent~tion from 40 to II~0 mi/llgrsms per k/logram. "l'nLs wls attrib- utable, in part, to different l~boratow m~ods and, in p~rt, t~ the fact that there is no national quality control or laboratory ,ccredltation process for these isbs. There is ~ no equipment ava~ble wl~ch could be conslde~d to The~ was • general consensus among officla~ that mors than 47.1~0 h~el of agHcul~zlre land in the court- try we~ contaminated by toxic chem/cais. Yet it would ,ppear that sy~temltic ev~lu•t~on of •griculture ~o~I organlc~ has not taken place. It w~ dLfficu]t to get • cise/nte~-.ta~on of the figure of 47,000 hecta~. It never dearly stated whether th~ ~gu~ repr~ented land which was totally contaminated or ff it wa~ the total area BATCo document for Mayo Clinic 27 March 02
Page 79: 39000936
of all the plots on which them was at least some contami- ~tion in one location or another. Example 2: Air MoniturinS in Poland Offl~ial~ at ~he Lnstitute of Hysiene adndt that there ~e problems ms~ntaL-~nS qu~it~ ~ee at thak n~otk of s~ons; partly ~ o~ ~r ~ ~, ~y due ~ ~ifive d~o~, ~d ~ due ~ ~pment ~bl~ ap~r to ~ a d~ ~t of ~h~ ~ ~e governs ~ ~ ~ w~ ~ w~ no{ ~ou~ ~ ~ av~ab]e ~ o~I ~ to p~ ~e ~a~ ~ n~ to do~. ~e pmble~ fac~ by ~e ~te o~ Hy~e we~ t~on. However, t~ ~s~te ~d ~ to ~ st~ to ho~, would ~clude the ~pi ~Ho~ as we~. For ~n~, the ~te had ~ ~Io~ ~ d~e~t w~ch w~ ~g ~ to meas~ o~d~ of ~en ~o~nd. Next, th~ iden~ a su~ of m~S w~ch we~ a~pmble and w~ch co~d ~ s~nda~. ~th ~ me{h~s by the ~r[y ~e ~ [or na~onal qual~ con~] w~ ~de when a~bo~e ~ata ~m the ~te of En~en~l ~t~on and ~he ~n~pi s~o~ we~ ~mpa~ for the ~me ~ and place. In genial, the level of a~ment was ~d~uate. in the wont ~, the ~p~le o~ the average a~l concen~on o~ ~ dio~de ~- ~e~ by 10 to ~ ~old ~ ~ ~ven ~on. For o~d~ of sen, aH ~mpa~ fell ~t~ a 2 fold ~nge, but ~nt~ d~e~nt ambient condi~o~ ~m a ~to~ s~nd~t. ~e o~cl~ to develop~ an eff~ve quaH~ ~m ~d the ~me ~e ~ the quaH~ ~n~l le~ themselv~. ~e~ w~ o~y one ~ s~met~ ~e en~ data coH~on system w~ch ~d vafidate ~1 da~. In o~ to ac~eve a "gold aga~t w~ch mottoes ~fio~ co~d ~ ~ds~, it wo~d ~ve ~n ~" to ~ the num~ ~ss s~mete~; but t~ wo~d ~ve ~volv~ problem ob~S auto~c ~n~uo~ mo~to~ ~ke Iong-te~ ~mp~g ~o~ f~s~le ~ ~e~ ~ Fo~h p~u~. ~e system ~ ~ sboH of a~ffon s~photom~em (~nt for tden~s m~), m~s to mea~ add ae~, ~d ~ flow m~. At ~e I~l mo~to~S s~fiom, mu~ of ~pm~t ~ out of date ~d ~rly ~g. ff any s~di~ o~ ~t~ o~a~ (e.S. ~B's, dio~, ~Iven~) ~ve ~ unde~k~ ~ of ~e ~ ~ ~r and ~m~t, w~ ~ w~ ~ F.xample 3: A[rMonitorln~ in ~t~x~ The Institute has two stations ~or monitoring tmnsbound- ary a~" poBution, s~x air monitor/~g s"~tions in T~linn, four in Kohtla-Jarve, and two in Narva. The~- mea.su~e- merit capabRRies include dust, c~u'bon mono~dde, su~ur d/oxide, sulfate, phenols, oxides of nitrogen, ammonia, fmmaldehyde, ~I hydrogen fluoride. They have no bility of measuring airborne lead. The choice of what to monitor at each station is bared on the nature ot" the local emission sources. All stations measure dust and sulh~r dioxide but only one station, in Tallinn, measures all com- The air monitoring system is based on stab samples taken during thee one-hour l:~iods each day. Only one continuous, on-line monitoring apparatu.~ exists in the count~'y, at Kohtla-Jarve. There have been quality control problems with the system, the most serious ul' whlch con- cerns the measurement of sulfur dioxide. In 1~1, the method of measurement was clanged to one which would involve less cross-contamlnatiun with other su]h~r-based compounds. As a result, measured sulfur dioxide levels appeared to have declined approximately lO-fold. in addition, there has not besm any r~utlne air monitor- inS c~pabilRy in several other important locations, such as Kunda (site of a heavily polJuting cement plant), 5Lllam~e (stte of a che~cal facifity of strate~c importance under the old Soviet regime), and Kehra (site of a pulp mill with significant airborne e~uents). Because the Institute has tended to operate autonomously from the Ministv/es responsible for reg~lating environn,.ent~,l pollution there have been few special collaborative efforts involving air monitoring. The only example we could document took place in the town of Saka, near Kohtla-Jarve, in collabora- tion with the Institute of Preventive Medicine. Example 4: Blood Lead in Central Bohemia This example concerns lead exposu~s to child~n near the smdter in Pribram, The problems in PHbra.m ~e no doubt compounded by the fact that the plant is 200 years old. Du.dng the 1960s it was en-dtting appmx~tely 600 tons of lead per year into the environment, although by the 1970s t]~ had declined to 2,50 tons per year. A study of lead exposures in ch~dren during the 1970s demons~.-ated vm'y high blood lead leveL~ at 2 schools within 10 kilome- ters of the plant. This helped to dr/re a modernization gram, such that by 1982 emissions had declined to less than 25 tons per year. Between 1986 and 198~, • second study of child lead expo~un~ was initiated. It w~s similar in desl~ to the first one, involving 200 chi/dmn from two schools within 10 ki]omete~ of the plant and 100 contzols f~om the town of Mrdchovice. The children wee aged 10 to13. The average nma.vnmd blood lead levels in boys m~l girls micn~rams per deciliter in be/oh schools. Even in tl~ control town o~ Mnichovice, the average blood lead levd exceeded 20 mkregr, uns per deciliter, in North Amerk:~0 chfldnm in a ~ blood lead a~ea m~,ht have an avua~e level of 15 BATCo document for Mayo Clinic 27 March 02
Page 80: 39000936
certlng to find out that, whe~ the blood lead samples were n~'e~ted In a eelS~ laborator~ the remlt~ were approxi- mately Z5 time~ lower ti~n ~e orlgt~l mea.~--en~en~ This fac~ alone makes the data imp~le to Inte~'p~t. It aL~o raises questions about the hill range of query cvn~ i~ue~ which the public health ~/stem face~ when dealtng with laboratory analy~i.s. For L'~tance, the moet likely explanation for the ~ in ld~>d lead value~ ~ve ~ do ~ w~ not ~ ~o~ on bl~ w~ ~ ~t ~ wo~d ~ve 1~ ~ t~ ~ ~h ~pl~ H~, o~y one p~ Ad~bl~ lead ~ ~ a ~ q~ ato~ a~on ~ a ~p~te ~ Such ~pm~t sho~ ~ly ~ ~ ~. At the ~e ~e~ was one at • e ~te of Hy~ ~d E~de~o~, b~t it was ~dy ~g h~y ~ BATCo document for Mayo Clinic 27 March 02
Page 81: 39000936
Annex Two Temporal Trends in Life Expectancy BATCo document for Mayo Clinic 27 March 02
Page 82: 39000936
Figure A2.1 Temporal Trends in Life Expectancy- Males Li~e ~cy. Year I Year 2 (1949-52) (1960-61) ~ Czechoslovakia ~ Poland ..... Hungary ..... Canada -- -- -- United States ---- Sweden ...... Japan ...... Bulgaria Source.. Uni~"d Nations and World Health O~anizaiton, Figure A2.2 Temporal Trends in Life Expectancy - Females I j S5 [ ~ f I Year 3 Year 4 Year 1 Year 2 Year 3 Year 4 (1975-76 (1987-89) (t949-52) (1~.61) (1975-76 (1987-89) Czechoslovakia ~ Poland ..... Hungary ..... Canada -- -- -- United States ------ Sweden ...... Japan ...... Bulgaria $ou~r. United Na~ons and World Health Orl~ani~tion, va~o~ yea~-~. BATCo document for Mayo Clinic 27 March 02
Page 83: 39000936
Temporal Trends in Infant Mortality c~ BATCo document for Mayo Clinic 27 March 02
Page 84: 39000936
]~igure A3.1 Temporal Trend~ in Infant Mortality - Males Figure A3.2 Temporal Trends tn Infant Mortality. Females Year I Year 2 Year 3 Year 4 (1949-52) (1960-~1) (1975-76 (1987-89) "---" Cze~mlovakia ..... ------ v~o~ ye~. BATCo document for Mayo Clinic 27 March 02
Page 85: 39000936
~r~ Annex Four Summary of Human Health Problems and Major Industrial Plants Located in Pollution "Hot-Spots" in Bulgaria, Czech and Slovak Republics, Hungary, Poland, Romania; Latvia, Lithuania, Estonia, Belarus, Ukraine, and European Russia This summary outlines those em,'h-onmenta] health prob- lems in Centr~l and Eastern Eva~pe for whi~ m~son~bly credible epidemiologic data are available. It ~ meant to be a comprehensive summary, but there are obstac/es to achieving th~s goal. Health outcomes in the varlous r~gions w~th similar chemical expo~u.re problems have not necessarily been investigated to an equal degree, and di~- /erent methodologie~ of va~/ing credibll/ty have been used. Th~ is particularly a problem for chronic and multi- lactorial diseases wh/ch requ/~ advanced eptdemtologic me~hods that are not commonly understood in Eastern Europe. Thus, the following summary draws attention to those chemical expo~'e problems wlxich have i~-en •de- quately studied, but does not mean to imply that other, well recognized episodes of en~,~onmental pollution or degradation have not led to human health problems. The problems described here are primarily the ~.su]t of exposures to lead in ai~ and ~o~1, airborne dust, ~ diox/da and other gases,1 and n/trate in water. 1. Places where there i~ • problem with ovsre~o~ur¢ to lead among children (37 locations in 7 countfle~): This problem is important because it may lead to , neurobehavioral defidts which will have long term effects on children's educational attainment. Evi- dence of neurob~havioral de,tits emong children has been focnd in ~verai of the k)llowing • )Poland. Ka|owice Wojewodsh/p---Szopienlc~, Miasteczko, ZygL~n, Lubowice, Zabrza, Toszel~ Bytom, Bojszow, Brzezin); and Brzozowice. Legnlca-Glogow ~rea--near copper imel~e~ (note: quality con~ol problems with blood lead dam). b)Czech Republic. Central (note:. qua~ty control l~oblems with blood lead data). c) Hu~8~-y. Inner Budapest, Romhany, Szoinok. d)Bu|garla. Plovdlv, Asenovgrad, Kunizh~ (msult~ of lead studle~ of •dul~ in Voden, Ka'emLkovi~i, Jana and Pemik imply that the~e are probably overexlx~m~ to children, too). e)Romanla. Bucharest, Coi:~a Mica, Bala (probable). D Russia ~u~opean).2 St. Petersburg, Be~'e.zzLikt, Podol~k, Yamslavl, Samara, N[~ny~ Novgor~:l, Ulyanovsk, Ro~tov-na-Dony, Ku~sk, Astra.ld~an. g)Ukralne. Kostiantynivka (probable). 2. Place~ where there a~e documented aaso~ationa between acute respiratory diseases (linusifia, phar- yngitis, bronchitis and laryngitis) and air pollution (46 locations in 10 countries): a) Poland. Krak6w. b)Slovakia. Bratislava. c) Czech Republic. Central Bohemia-- Neratovice, K~. lupy. Northern Bohen'~a-- Usfi nod Labem, Teplice, Most, Chomutov, Decin. d)Hungary. Dorog, Ajka. e)Bulg,uta. Ruse, Vratsa, Devnya, Srednogorie, Krek/kovts~, Asenovgrad, Shvistov, Dim~trovgrad, Sofia, Gabrovo, Vama, Kameno, Burges. 0 Eatm~ Harva/Kohtla-Jarve/Sillamae me•, Kunda. g) Ll&u~a. ~onava, Kaunas. h) Larva. Olalne. Galati, Savinest, Suceava, Hunedoara, M/ntia, O~elul Rosu, Navodari, Remicu-Vllcea. j) Ru~sLa 0"-'uropean). Arkhangelsk, Vo~kresensk, Chebolcary, SI. Petersburg. 3. Pl~ce~ where there are documented between chronic re~tratory dl~a~ (ch.mrdc brenckltl~/emphy~ema and *.thn~) and alz poliu- ti~n (29 locations in 9 cotmtrles): • )Poland. Regional --,~(x:iation be~een ,SO2 level• and chronic bronchi~ and ~sthma rites tlu~ugh- BATCo document for Mayo Clinic 27 March 02
Page 86: 39000936
b)Czech Republic. Northern Bohem/~--Usti L~bem, Teplice, Mint, Chomutov, Decln. c) Huns~/. Don~, AJ~, Nagyteteny (in D/~ct 22 of Budap~t), Bonod County gtr~mcbtrcika and M~kolc). d)aul~.H~ Ru~, R~lo~ Vm~, Devnya, Smd- nosode, Plovd.iv, A.~novgrad, Kre~x~r~i, Perntk. e) Estonia. Narva/l~htk-Jarve/Sillamae area, Kunda. f) Mthu~n/a. Jonava, Faunas. ~Lat*l~. Ola/ne. I'0Ru~ia ~umpean). S~e~IRamak, U~a, Chayk- ovskiy (Perm obl~0. i) Romania. Turda, CoF,.a Mf~a. 4. FLtces where there b retsonably stmnS evidence o! ~ connection between excess fnfant and lun8 c~nce~ mor~alt~ ~nd s/r pollution (8 loc~t:lons in 3 c~mtrie~): a) Poland. ]~tov~ce--Inf~nt mortality in ~eas ~Ith the highest du~t levels. Krak6w--LunS cancer in mla6on to ccmmurdty exposures to steel mill em~sions. b)Czech Republ~c. Infant mortify (e~pec~/y po~t- neonatal respiratory mortality) in regions wRh the hlghe~t dust and SO2 levels. c) Rus|is (~uropean). ~ Nizhnyy Novsorod, Dzerzh~k, St. Petersburg, LiF~k. l~:Othe~ phces where correlations between air ffon and adult morality and/or cancer incidence likely v~d, but require further investigation, include the mlrdng dis~ct~ of northern Bohecds GunS cancer, all cancer, to~ mortality), the mo~t polluted dlstrlcU of Centnl Bohen~ (to~ mortal- ity), ~ n~d I-L~nom resfon of 51ov~ds (total mor- t~Ltty), ~ (to~l mort~ity) ~:1 the m/nin$ district of southern Bulga~ aunS c~ncer). 5. Phce~ where there ~ docum~ted as~tions tb pollut~on (18 loc~tions in 7 c~u~dee): a)Poland. Krak_w....~luced pulmonm7 f~m~on amon~ adul~ ma]es exposed to acid ra/n ~ don~. F, at~wice--average henoglobln leveb mothen and children reduced by about 20% below normaL b)Czech Republic. l~tes o~ low birth weight ~re incre~..d in the r~st~n, w/th the ktShest levels of dust and Centrsl --increased rste~ of "smsll ~n" ~t~onsl BATCo document for Mayo Clinic 27 March 02
Page 87: 39000936
e)Ru~la (European), C~erepovets, ICmnensk-$ha- k~t~kiy (Rostov oblast), "t3~-naus B~I]~ya), Vladlkavkaz. 8. Other Health Effects of Contmmlnafed Dfink(ng Watt~ Supld~er. a)lJtvia. Riga--large waterborne hepatitis A out- break ]elgava--lar~e milk-borne dysentery outbreak based on contaminated water ~upply. b)Romania. ~ogenic ~ul~tances exceeding standards have I~oen measured in water samp]e~ from ~2 of 41 d.Lstricts in the coun'ny. --chlorkmed pesticides found in many water supplies arnund the country. c)Russ~a {Eu~p~.n). St Pete~burg, Murmansk, Volograd, Ku~gan, Novgorod oblast, Mordov~n Republ~c. o 9. Places w~th otherpwblems: a) Poland. Krak6w-.-ongoing i~oblems with fluoro- sis near an alumin~'n smelter. 'Baron; Silesia~h~gh prevalence of methemoglo- binemia near Hgnite power plant. b)Slovakla. Michalovce--PCB e~postu~s, with mini..epiden~c of Potter's Syndrome (congenital aSenes~s of kidneys) in the late 1970s. c) Behu'us. Gomel oblast--thyroid cancer in children foHo~'ing Chemobyl. d)Estonia. Widespread beach closures to protect against the spread of i~ec~ious dkease. ~) 1.atvlt. Water supply in Daugavpils d~cl t~#ice Hungar~ in the last two years to protect a@inst chemical spills upstream on the Daugava River in Belaru~. Brocenzi--large-scale comm~ty asbestos expo- Liepaja--mu]tiple concerns from electromagnetic radiation from radar stations. Olaine--disordered in~-nune hm~cion in adults. i) Romanla.Several towns/cities with high airborne asbestos levels. Suceava--neumlogical symptoms in children exposed to carbon disulfide. g)Russla 0:umpe~O. Katinsrad, Novgonxt, ~ e~k, Syktyrkar, Kandalaksha, Cherepove~--l~h atrborne benz~)py~_ne levels. Dzerzhinsk~ Serpukhov--High levels of polychlo- robiphenyls in air, ~tl, water, veSetation, and breast milk. Ufa, $hchelkovo, Cl~payevsk, Dzerzhi~k, Mos- cow, M~-mansk~hish concentrat~or~ of diox~n in the soil on i~ounds of industrial plant~ and in the ashes of waste incinerators. h)Ukraine. Thyroid cancer in 3 contaminated a~as of Ullage following the Chernobyl accident. The information collected and evaluated from nine ~ countaies provides the following overall picture:. The predominant envimnmenta~ hea/th threat In Pol,md is the re~o~l hot spot in the Kato,,vJce-KrakcSw area. T/c~t~ , to human health are m~tly due to atrbome exposu~s, ~md secondarily to del:~sition of metals (especially lead) in ~oil. ~d~spr~d water pollution has no~ bee~ shown to be • significant risk to health at this time, l~eSumably because there is a t~adition of not using tap water for drinking. Air pollul~on in the mining districts of northern ~hemla forn~ a regiona~ hot s~ot, which ~s the primary source o~ envlmnmental health problem~ There are smaller areas of concern in industrial ate.as of Central Bohemia and Mora- via, as well as in Prague. As in Poland, water I~llution is not a ma~or cun'ent concern w/th respect to human d~ $1ovak ReFubl~c The p~Rern in the 51ovak Republic is different from Pohnd ~d ~e ~ Re~b~ ~ ~t ~a~ ~ ~g water ~ ~ a~ ap~r to ~ a silent problem. ~ ~ ak ~ufion ~m s~c p~n~ ~ a ~ of s~ ~c l~flo~. In Hungary, areas with human health problems in relation to the envLmnment tend to be old industrial areas with a confluenc~ of aL,'borne pollution souses, ~uch as ~o~od County and the indust~'iM areas of Budapest, or areas with a single major pO~t source, such as A~. ~terbcrne exposures to rdtrates are important as wen in Borsod Coun~ tnd there are problems with naturally.oco.uring arsenic in water in B~k~ County. Bul&~ia The pattern in Bulgaria is similar to H~gary with • mix- tu~e of single a.~d multiple p<~t ~ of air pollution ]:~,dorn~a ling, However. the number of areas with docu- me~tec[ ~:,clations he.Teen air pollution and human health outcomes is much larger in Bulgaria ~ in Hun- gary Nitrate pol~u~lon of wate~ is a widespread problem, affed~ng ~g water supp1~ea in rur~ a.r~s through- out the Western part of the country. Most of the ~ pollution related problems in R~ are due to intense exposures from sinsle Foint sources, These tend to be clustered in certain parts of the co.arty0 eape- BATCo document for Mayo Clinic 27 March 02
Page 88: 39000936
dally In the ares of "l~ansylvan~ near C3u}. Nitrate pollu- lion is common In 38 of 41 dis~'icts of the cotmtr~. Aside from prodlg/ous dust emissions from a cement In Ku.nda, Estonia, and a small number of other local con- cerns, ah- pollution problems in the BeIHc Countr/es tend to have less health sign/6cance than in other pazts of Cen- tr=l ~nd Eas~'ern,~ Europe, Irmtead, problems w/th water pol- lution havecome to the fore. Rural Lithuania has problems with Mtrat-~ wMch are of human health ~ign~cance. Riga has had an eptdendc of waterborne hepatitis A as a of • tempor~/lack of coagulant to treat drinking wat~ ~mm the Daugsva Rlve~. All three cotmtrie~ have had to close beaches in recent year~ to prevent the spread of infec- tious diseases due to inadequate sewage trea~ent in ad~- cent ~.Iemen~ It is not dear whether or not the pri~pa] environmental health problen~ In Russla a~ the same as thosein the re~t of ~ ~ ~ E~. R~sia's s~e and ~e~ ~v~i~ ~ ~nt o~d~ to ~o~ ~e ~k ~ ~de mo~ ~t by the fa~ t~t ~]~ant ~o~- Uon ~, a~ ~ one ~te, ~n g~t~ by ~ ~I~ ~t ~mt~ ~d ~e ~. BATCo document for Mayo Clinic 27 March 02
Page 89: 39000936
Table A4.1 Major Industrial ~ located in pollution "hot-spots" lluli~ia Dim, im~v|rad Kurd~di Plovdiv ~ Za$o~ ^senvg~l 'Pemik Kuklcn Vcd~n l,lll.4 211).2 3?4.0 11t6.7 q7.2 i A • I 1 A,C • Pb.C • I Fo. A.C • I~o,C • I I. 2 A,C • I~, A, C I ! A N~ber if ~ clm:mk~ cbemksl I
Page 90: 39000936
Table A4.1 (continued) Shvismv A ~vo A Vama A I F,~mgna • A p.~og ~ 2 Norm ~: 29.9 Mo~ 70.8 A. C * T~I~ " 55.5 A. C C~mumv ~.2 A, C 24. I I I ! :3 I l 9r 9 OOG
Page 91: 39000936
0 LCjbO .<DOOCJ Table A4.1 ~ md lironom Odor Mis~olc 174.7 • 392.2 442.9 21.4 l 1 I I 2 2 I 31 2 4 J 8 1 2 2 I 4 6 2 3 6
Page 92: 39000936
Table A4.1 (cor~inu~l) and and fro'row and ' • ¢hmsk:~. chamka~ ,:" Northern Tmusdsnubiaa Dom| Tam C~nn'sl T~b~ ~gio~ ~y~ r~ ~wk~: C~w C.P • • I 13.0 29.8 19.6 24.8 73.8 • 1 • I I • ! I • I 24 2 2 4 139.2 131.5 ! ! 2 3
Page 93: 39000936
Table A4. I I 1 ~able contbmes on O~e follo~t pate)
Page 94: 39000936
0 0 BATCo document for Mayo Clinic 27 March 02
Page 95: 39000936
Table A4.1 24.8 63.8 643.6 2,32:~.0 • • 117.3 • 9.3 6 • 108.0 • 305.0 • .. 297..~ • I I r~ 6 5 I0 ~ 13 IT 4 I 2 | • (T~le conlbzuez on t~e follo~ng page)
Page 96: 39000936
BATCo document for Mayo Clinic 27 March 02
Page 97: 39000936
O Table A4.1 Vilaius i~p'u 484.4 $0.4 A. C • A.C 2 I I I I II I (Table con~nue+ on ~e follo~n! page)
Page 98: 39000936
500 3~464 1 I 1 (p~mupuoo) r~,v aiqRL
Page 99: 39000936
Page 100: 39000936
Table A4.1 ~~ C 991z$£~00~;
Page 101: 39000936
O0 Table A4.1 i~p'm (~o) $17.0 1 ! ! A C M P ~ ~ ~ ~ ~ly ~ ~M~ of a ~x~ ~i~ ~ sir ~t~n. Z91~O0~
Page 102: 39000936
Annex Five Heavy Metal Contamination: Selected Data Table AS.l: Lead and cadmium in potato¢~ in ~¢lected Iocalltte~ in Poland (a~"aF az'wt'ntratlan~ i~ l~ ~ mtllian) WHO Gu/dellne 0A 0.06 Kit o~ic. Province 0.91 0.17 Zyglin ~.17 0.22 Z~bkow/ce Bedzinslde 1.47 0.~ Chorzow 0.17 0.15 W~b~yo~e 0.19 0,0~ ~l~kie ~ 8yd$o~kl~ 0.25 0.~ Table ASOa Lead and cadmium in 8arden plota in Katow/ce CufivaHon standard 1~ 3 M~e ~ 1~12 Peak ~ Hb~ 1~ (d) Table AS~ Me~ con~a~on of ~d ~ ~e ~ ~d SIo~ RepubU~ ~ ~d ~o~ Potatoes 13.~. 0.2~ 0.~'/5 0.0~8 0.0~9 0.0014 ~e~ce ~ ~n~on to ~ke ba~ on ~ome ~u- !~2 1~1S 31 ~ 14 2 BATCo document for Mayo Clinic 27 March 02
Page 103: 39000936
Table A~A: Le~d amtamizmtlon of fo~d Szown Jn FlovdivlAJenovsr~d, Bul&mil, 19~1 Tomatoes . 006 Fot~.to~, 0.92 Apples 0.~.~ Gr~ ~ 0.~1.10 S~w~ 0.~I.~ Table ~ BATCo document for Mayo Clinic 27 March 02
Page 104: 39000936
Annex Six Ambient Air and Water Quality: Selected Data Table A&I: Ambient air qutlity ~ selected l~llUe~ tn Central ~d ~ E~pe O~she ~95 8 66 Vltebsk 166 II Poletsk ~3S 19 Mo~lev 133 14 ~mel 103 9 Mi~k 101 4 Brat ~ 13 Bu~8eHe (19B9-~0) Dim~trovgrad 530 119 0.7 Sredno~ofie 400 ~ya ~ 2B 0.3 Ptna~hte 3~ ~ O~ ~ut~hall 310 103 ~t ~3 67 0.4 Rule ~ ~ 0.4 Plovdlv 280 ~ 1.0 31 Stare ~gota 2~ ~enov~ad ~0 ~ Z6 Pemlk 24~ ~9 0~ BATCo document for Mayo Clinic 27 March 02
Page 105: 39000936
Table A&I (~F~i~J) • ves~e~, 1981~8) ~ 91-I~ ~126 ~114 " Most ~I~ ~176 .1~.~ 51-1~ Tep~" ~111 87-141 .15 ~ill ~e' ~-1~ 2~I17 52-71 Mel~k 52~ ~ 0~1.6 ~kolov 7~12~ 2~ P~ 47-110 I~113 ~ava I~-139 4T-~ ~r ned Hmnom >!~ I~ ~A-Z indus~s] zone Mlskolc ~ 27 Ocd 61 M (site 1) 20 13 5.3 (site 2) Tran~snubitn: D0m~ 114 % 39 ~zt~om 1~ 57 ~omtmm ~ 52 Ta~ 1~ ~ 43 Tstublnya 101 ~ Tramdanubian: F~ 32 ~ Sz*szvu 51 2~ 20 5~o~ 2.0 L~tv~ (1989) Vent~p~ 100 20 Deugev,pib 100 < I0 Uep.~ 1~ < 10 ~ga 1~ I0 O~e I~ < 10 U~,,,n~ (1F~)) Y,~u~. 300 10 StauJ~t 330 10 Kedein~ 200 10 Y'd.,du~ 100 10 l~alp~,, !00 10 ]on~va 100 10 BATCo document for Mayo Clinic 27 March 02
Page 106: 39000936
l~bnd (T~P dst~ for f~r I~7 ~ 1~) R~ 318 ~w 315 T~ ~ ~ ~ 174 ~ 112 S~e~ 110 1.11 BATCo document for Mayo Clinic 27 March 02
Page 107: 39000936
Table A~,I United Stat~ (dry av~-~) ~3 ~ < 0.4 ~ C~da (d~ avers8.) M 13 < 0~ 43 ~dlan ~ot ~" 0.~1.0 SwOon (d~ ~v~) I0 18 36 Table A~ Db~buflo~ of ~ ~ Poled (n~ ~u~S ~to~) ac~r~S ~ ~bient ~ qu~ ~ Air ~t~ (m~ ~ ~ ~) < 20 2~ ~ ~1-80 81.I~ > ;01 ~t 5 1~ 28 21 3 29 5~ dlo~de 24 26 13 11 13 13 NOx ~ ~ ~ ~0 0 5 Table A6~ ~ q~ ~ S ~om~m o1 ~ pl~ Jonav~ U~u~ Ammonia 200 30 890 130 440 Formaldehyde 35 31 1400 140 160 Sul/ur dioxide 500 230 520 30 670 Nitrogen oxide &q 30 410 150 30 Hydrogen ~luodde 20 20 67 ~0 gO Table A6,4 MedLtn ¢oncent~at:ion of air pollut~nt~ by ~ ~m pe~ of ~dus~ zone ~ Zapow~ye, ~e Dust ~ 1330 1400 1100 7oo Su~/ur dioxide ~0 810 820 720 4~0 NIl~o~en oxides 10 I~ 1~ 120 ~ Hydms~ c~o~de ~ 2~ 1~ I~ ~r~n mono~d~ ~ ~ ~ ~ I0~ BATCo document for Mayo Clinic 27 March 02
Page 108: 39000936
Y~towJce 1.2 42 0.47 13 ~ 1~ 8ytom 1.6 13 0,~0 17 ~ 162 C~zow 1~ 8 0.~ ~ ~ ~ D~b~w~ ~o~. 6~ 39 0.~ ~ 31 1~ Ruda L5 8 O.~ 10 I~ ~ Ryb~k 3.6 11 O~ ~ 14 ~ S~et~o~ce ~1 19 0.~ 11 14 1~ W~ht~w 4.8 ~ 0~ 4 ~S 95 ~brze !.9 12 0~1 8 18 117 Table A6,6 Indicator volat/le aromatics in the air:. Vac, Hu~8~ compared wi~ ~elecled V=c (1990) 1 41.0 76.9 2 38.0 83.4 S9.5 3 31.2 106-q 4 45.6 93.0 V~ncouver (1~7-~) I 21.2 ~.g 17.4 2 2L0 76.9 W~dsor (1987-88) 0.1 ~.0 15,3 Mon~eal (19~) ~.3 32.0 .. Table ~6.T Po~u~ ~ ~wat~ T~ce, ~ R~ubH~ ~9 pH 4.~4 3.78 6.10 .. Hardness 0.2~ nuncd 0,1 1.0 ~ 7.~ ms ~ ~% - 15.6 ~8 kS ~S ~ m~ o - ~1 10.8 ~ ~0~ mS 0.1~ . 5~ ~.1 ~ p~* ~ nS 3 - 119 1~ ~ BATCo document for Mayo Clinic 27 March 02
Page 109: 39000936
Czech Rq~bLle., ~.g~ . BATCo document for Mayo Clinic 27 March 02
Page 110: 39000936
Annex Seven Health Status in Relation to Environmental Pollution: Selected Data "fable AT.1 Relative prevalence of chronic b~mnchltis in Krak6w, Poland Non-smoking villagers 1.0 L0 Smoking vj]lagers 2.0 2.0 Non-smoldng suburb~nite~ 1.6 1.4 SmoklnS subm'banites 3.0 1.7 Table A7,2 Natua'e ~w.hool and hematological ~-unct~on in children f~m no~r, hern Bohemia, Czech Republic Study | Erythrocyies 4.6 4.9 Hemoglobin 123,1 128A S~dy II Erythrocytes 4.5 4.7 Study Ill Erythrocytes 4.2 4,3 4.2 .... (~ < ! SD below norm) ' 36.0 14.0 ...... Hemo$1obin 113.5 117.6 117.3 .. 113.8 l% < 1 SD below norm} 42.0 15.0 ...... Lymphocytss with active nucleoli (%) 11.9 4.~ 6.1 7.1 .. Chronic kidney/urinary tract dl~ases 0.9 1.1 1.4 !.7 Nonspectfic lung/airways di~ases 0.~ 2.9 0.~ 1A Aller~les 1.7 2.9 2.0 4,0 Mental Illnesses and "detects" 0.5 |.l s~ dl~,,, o.~ ~ 0.7 Snd~,in~ O/her ch~nlc 0 BATCo document for Mayo Clinic 27 March 02
Page 111: 39000936
Table A7.4 Pr~slence of anenda in Estonlaz industrial cities compared with Ta.,tu Tartu n3 0 2.6 0.8 Kohfls-Jarvt 1.8 7.0 18.2 6.9 Natva 10.3 26.7 18.2 10.9 S]lhunse 4.3 5°0 20.7 13.1 Table AT.,q Air ~ol]ut:1on ~nd abnonnsl presnsncy In Okr'~e: two lndust~ cities compared with Sim~en~pol, 1981-8~ MaHup¢l 920 ~4 11.7 4.2 2.2 0.6 Zaporozhye 41S 19 8.8 3.4 1.0 0.5 $i~rtropol 12~ II 3.8 1.6 0.7 0.3 Table A7.6 PC13s in ~at t~sue in autop~ s~mples flora the Slovak Republic Bratblava n=16 4105 n:9 2243 Martin n-lS 104S n-7 920 Trendn n~10 3142 n-4 2622 Table A7.7 ~timated number of workers exposed to toxic asents at work at levels above the mzx~num allowable ¢oncent~on~ Noise 372 D~t 210 Vibrations 49 Welding fumes 28 ~lvents 12 P~d~ 10 Poly~c s~m, Uc hyd~r~ I0 Car~n ~noxide Mans~ and o~ ~ Z7 N~ 7.4 ~ad' 6.0 ~n ~de 0 BATCo document for Mayo Clinic 27 March 02
Page 112: 39000936
Annex Eight PCB Food Contamination in the Slovak Republic 0 0 BATCo document for Mayo Clinic 27 March 02
Page 113: 39000936
Page 114: 39000936
Annex Nine Places Where More Information is Needed Plsc~s fn Central ~nd ~te~n Europe WherePopul~t~ons Are Llvin~ ~d at ~e ~o~ ~ted ~ ~ ~ I. ~ Repu~e, ~ ~, ~iow, ~ ~o, M~ck ~ B~ga~--P~hte, ~ ~go~ 3. go~~, ~m 4. Po~nd--W~b~Me ~. ~~k, PolomklNovo~l~L M~ 6. ~~I, ~nmL ~ 7. R~s~tl~ ~plefe B. locations for which h~ther L-dormalion is necessary I. Czech RepubHc~Brno, Kosice, P~eviclza 2. l]ulgada--Pleven 3. Romania--Dml::~a "Rcnu Severin, Tusu Jlu, "lhr~u Mutes, Satu Mare, Ploesti, Pial:~ Nesmt, Br~sov, Onesti.l~cau.Bors~sti ~ion 4. PoL~nd--Jeleniogorsld r~=S/on,Tomn region 5. l~-~s~l~bm~k, Groclno, O~ha, Sve~lob, o~sk, Vitebsk 6. Hunga~T--Tata, Tatabanya, Esztergom, Komamm 7. Ukrztne--Obuhov, Drogobych 8. Fatssia--curren~ly inwrnplde BATCo document for Mayo Clinic 27 March 02
Page 115: 39000936
Annex Ten Occupational Health There is a high degree of overlap between the locations of environmental health concern and the areas of industrial concentration in Central and Eastern Europe. This is not surprising since three of the principal environmental health threats ar~ dust. toxic gases, and lead: all of which are emitted in large degree from industrial ~ourc~. To the e~tent that these polluting industries affect both the health of the communities in which they are located and, also, the workers who work there, a reme~atien s~ategy which targets environmental health problems will also be ~'fec- rive in captuffng workplaces with significant occupational health problems. The be~t example of th~ is lead smelters, where significant community expo~ur~ to children and in-plant expo~ur~ to worker~ ~m to coexist ~'er3rwh~r~ they have been meas'u~-,d in tandem in Cen~'al and East- ern Europe. However, there are some important exct~. tions to this general pattern which need to be carefully consider~:l in ~he development of an environmental action program. Thee include two types of locations: where environmental health problems exist in the ab~nc~ of occupational health problems and, conv~m,~.ly, tho~ where occupational health problems exist in the ab,~nce of • nvL-onmental health problems. In m~ny locations in Central and Eastern Europe stack ~n~ti.~ions from industrial sources are pn:~i~gious but plant exposur~ are trivial, or, at least, no wor~ than would be expected in comparable facilitiea in the West. This would appear to bo true/or many coal-fi.,~d power and heating stations as well as certain c~ment plants, ~uch as the one in K~nda, Estonia. But the phenomenon is not confined to these sorts o! fac~tiea. In 8~'a], the e.nviron- ment inside industrial facilities, exc~t in Rom~ula, ~ to he r~latively clout to Weslem norms than conditions in the ~djacent communities, despite • widespread lack of basic safety equipment and exceec~gly lax enforcement of health and safety regulations. A good example of this is the Hut• Sendzim2ra steel works near Krakow. The facility has historically been a principal souse of air po~Jution f~r ]O'akow and was represented to ~ as • dangenms place to work, since only 13 l~-~'nt of the workers were sa~d to ~ without • d~bility. However, our vbit to the facility revealed that this statistic distorted the real/tias of wor]dng conditions in the p]ant, which were no more threatening than an average North American steel pisnL It turned out that the high rate of disability could best be explained as • response to the exceed/ngly gene~us disability pension benefits that existed for workers in heavy industry in Poland, rather than the workers" experience of di~biiity Routinely reported data on worker absenteeism and occupational di.~.ase across Central and Eastern reveal a pattern which supporl~ these pe~-,ptions. Absen- te~sm rotes tend to be high (probably reflecting l~mefit- driven behavior), while occupational disease rates tend to be no higher than in Western counlzies. This latter state- merit, however, must be taken with thr~ impertant qualio fications. First° certain occupational diseases are unden:li- agnosed and under.r~x~z0zed i~ Central and Eastern Europe. Most important among this group are occupa- tional cancers, which have ~c~ivecl no n.~'ognition at all as occupational diseases and very little investigation has been done of them. Second is the problem of political inter. K-fence in the mix~r~ng of occupational disease. In Czech- oslovakia, a Folltical decision was made in the early 1980s to suppress data on silicosis ca.~s at the national l~veL In Rcman~, ~mncial incentives we~ exerted on plant physi- cians to keep the numbax of reported cases of occupational diaeas~ below a tavSe~ed value on an annual basis. Anec- dotes • bout Ires systematic forms of mls~1~orting came out in other countries. Finally, the prevalence of the bev:ulosis, c~rtainly is hisher among Central and Eastern European workers in exposed occupations than among their counterparts in the West. This third qualltication of the ocoapational ~ tisties Imints di~ctly to the natu~ of many of those places where there a~ eeve~ occupational health problems in the absence of environmental health prelims. Thas~ t~nd to be places with heavy worlq~lac~ dust exlx~xu~s in the absence of large scale ~misslons into the community, in • pply to many underground coal and uranium mines in BATCo document for Mayo Clinic 27 March 02
Page 116: 39000936
Central and F.~tern Europe. A good examFle is t~und in Fecs, Hung~aF, where • uranium mi~e ~ai a cc~ m~e were both in production until m~ently: The~e is currently • mh~-e~demic of lung c~er which began among the m~ners ~rom the (now defuncO u~nium m~e. wl~le, at the s~me time, the coal n-~ne (still oFemtin8) ~ been pro- duc~ng 100-120 new sEicosl~ ¢~se~ p~-year among a work- force of 4100. Non~heles,~, community air quality is not of particular publlc heath concern. Similarly, eplderalolol~c data for uranium miners in Czechoslovak~ suc~est an ongoing lung cancer risk there. To be sure, there are exam- ples ot e~pec~ly dangerous workplaces, other than u'~nes, in Cen~'al and Eastern Europe which do not coexht with sig'r~cant commur~ty eXlX~mes. But, when coun- ties other than Romar~a are considered, tt is lair to say that a large propo~on o( the dangerous workplaces that do nat lead to commur~ty exposures a~e in the enerffy sec- tor. and should become Im'ge~ o~" closure or zeinvestment a~ part of a program of reform in that economic sector. Rc~an/~. As has been h~nted at above, Romania is an exception to h~-se general hales. The former ~.gime there Fm~ued a poUcy of indus~-ia1~afion d~plte the human cost. It provided stum~gly generous danger pay' to work- ~ In m.ine~, z~i~ls, and smelters which were based on m~bi~t in-plant air quality measurement~ done periodi- caUy by the Centers for Medical Prevention. The scale of perve~|ty of this ~ncentive cannot I~e over~tated. In many locatlorm throughout Romania workers l~ve been zr~- tantly demandtz~ that dangerous working eond~tio~ be maint~ed in order to support danger pay which can drive thei~ wage rates to several time~ the national aver- age, In th~ context there appear to be many locations th~ou~hou~ the coun~-y with severe occupa,onal health ~blem.~. • Nationa] data ~d~cate that there are ap~n~x~mately 500-600 new ca~ of silicosis per yeaz produced in mines and foundries around the country, of width I0 percent have stl/cotoberculoda, The average time from fu~t expo- sure to disease is short, 15.5 yea~ in the mines around 5uceava dining the ~980s and 18.4 years in large foundries arotmd the country over the same time period. The large copper mine near guceava has a particularly stri}dn8 hla- tory of si.licosis. Of 2700 miners retin.d with permanent dLsabilS7 between 1953 and 1982, 61~ percent had silico- d~. The average age of retirement was less thaa 40 and 69 pe~mt of thes~ men had lass than I0 yea~ of exposure. Tube~.tlosis complicate~ 24 percent of ¢a..~s. 5o f~r, 23 per- cent o~ the deaths among ~ sample of pensioners has been from sEicosis and the average time from reth-ement to death has been approxin~te]y 7 yearn. • in 1990 there were 246 confirtned cases of one-ti~ne expo~u~ {o ionizing radiation of more than 400 ntiUh-em in utah/urn mine~ =ad other workplaces. • Between 1986 and 1990 approximately 3.6 perrent of the workforce, or 51,809 workers, were exposed to carcin- ogera in the normal cotm~ o~ their work. In six dlat~cta, Oft, Giurgiu, Bacau, Vaalul, Prahova, and Salaj, more than ~0 pev:en~ ~f the workforce are expo~.d to carcinogca.~. The most prevalent exposure, in descendLn~ order, are t~/minera] oi~/c~rbon blar.k; polycydlc aromatic hydrtrmbons; hexavalent c~wm~am; ~ ~be~tc~ vinyl ~o~e~ ~ ~y~e ~d ~ ~d epi~orhy~ of ~d ~to~on ~ y~ ~e ~0~ p~nt y~; ~e ~on ~te~ h~ ~ ~ ~t. w~ ~u~ ~ n~ ~ of ~ ~ 1~; ~d o$ ~n ~de ~d ~c affd to~ ~ ye~. • ~ad ~t~ pmble~ We ~ s~ ~ong worke~ at ~e ~ p~t ~ Co~ ~, w~ ~ ~id to ~ de~ ~ the o~ p~t ~. ~ 19M ~d I~9 ~e~ We ~ 61-I~ ~ of a~te lead ~ y~ (~m a wor~o~ oi a~m~tely 3~), ~ ~ s~o~ of ~ve~ gas~¢ ~. ~ ad~o~ ~ ~ve ~n 11~120 ~ of ~c lead ~ on s~o~ ofn~, co~pa~on, aneW, ~, and m~e~te gas~c pa~. U~ l~d ~mp1~ Table A10.1 Urlnary lead leve]~ at the IM~ pl~nt, Copsa Mien, Rom~tla, 1989 Not o~y are these numbers extremely high, hut the ~t- ~d~ ~d~te ~e problem ~ even ~e =t~ go~ de~ h~ ~ a~p~ble wo~d ~ m~ide~ d~ge~ ~ ~e W~L • ~a t~ o~ ~ ~ hea~y ~ut~ ~th l~d ~d o~ m~ due to ~o lead smelt~ ~ the a~. ~ ~e Fh~ p~nt ~e~, ap~tely ~ of3~ wor~ ~r y~ ~ ~ov~ ~m work and &e~tM to ~uce ~g~ly ~ ~y ~ of I~d. ~e~ a~ ~ ~tiy 17 ~ of i~g fib~ at the p~nt, p~y ~on8 ~te~ workm. It ~ ~tem~g to note t~t • e o~ n~ w~ ~ ~ ~ ~ ~r 1~9 ~olufio~ wh~ ~ ~e ~s~le to ~ ~e p~t who ~ve ~c-~ ~i~~, ~d ~ ~e~ ~ve ~fly ~ M~ ~ ~ndifio~ a~t~y 1~ n~ ~ o~a~te bmn~, - ~ ~ a ~ y~ ~ow up ~dy w~ done of work- ~me l~ ~8~ ~m ~ ~ ~ ~bic m~. ~e w~ke~, ~.7 ~t w~ ~d to We v~ve ~t ~d n~lo~l a~o~; ~ ~t Md dig~ 106 BATCo document for Mayo Clinic 27 March 02
Page 117: 39000936
sd~Lficial Jibe~ plant In Suceava. In 198,5, 43 pen:ent w~e found to have neurological ~ndlnp conslstenl: with car- bon d/sulfide exposure, 22 percent w/th alcohol Intoler- ance, 82 percent with nerve conduct/on abnormalities, 48 percent with personality disorders, 4 percent with chromo- somal aberrat~uns, and 6 percent of births to female work- ers between 1983 to 1987 ended with • congenitally m,'Ll~ormed o~pring. • At the "Bicaz" asbestos cement plant, a spec~ chest x-ray survey of the workers showed that 15% had evidence of asbestosis. • At the vinyl chloride plant in I]orzesti, a ~oIlow.up stud), of workers from 197787 showed inc~-easing frequen- cies of Re)mauds phenomenon and acro-osteolysis, wb3ch are characteristic of vinyl chloride exp~ure. There have also been inc~ases in hepato-h~ary symptoms and changes in liver function tests consLstent with vinyl cldo- ride r~lated pathology. • In a Pesticide munu~acturing plant in Borzesti there have been problems with exposure to simazine/at'razine and carbamates. In 1991, 149 ~lative]y young workers exposed to the a.z/de pestiddes were evaluated. Eighty- eight were found to be suffering medically significant con- ditions: 6~ percent were experiencLng allergies, 38 percent had endocrine conditions, 22 percent had digestive condi- tions, 15 percent had cardiovascular conditions, 10 percent had respiratory conditions, and S percent had rano-sen/l~l conditions. Approx/mately 25 percent had hematological changes which were deemed to be "pre-le~kem/c" by a hematologist. On two different types of ch~mosomal evaluation, 13 percent and 8 percent of exposed workers and I percent and I percent of controls, respectively, showed a pattern of damage. Among the workers exposed to carbamates, a positive correlation was found between the prevalence of nerve conduc'~on disorders on elec. tromyography and the concentration of the ur~ary metab- ollte DDC-Na. Chromosome damage was found in 15 percent and 8 percent of their samples on the same two tests mentioned above. • In the galvanizing area of the Electroba.nat plant in T'm~osoara, a study of pulmonary function showed that 24 percent of the workers had forced vital capadty less ~ 80 percent of predicted (compared with 5 Pe~ent of cont~ois) and 20 percent had forced expiratory volumes less than 80 pesrent of predicted (compared with 8 percent of controls). Poland. National sLatistics are available for compens- able occupational diseases. The table below deta~ the five n~jor causes of occupational disease among the 9604 indi- vlduals (6031 msles and 3573 female~) who received new compensation claims in I%8. It should be noted that the leading canses of compensable ~ in Poland are not dissLm/hr to what is seen in North America. For instance, ff we exclude problems with Joints, which ~ to be hart- died as "injuries" in Poland and "dbeases" in Nor'oh America, then skin diseases, pneumocordoses, upper re~ piratory problems, hearing loss, and infectious ~ are all among the top ten in this par/of the world, too. On the other hand, the overail compensation rate of ?7 work- ers per 100,000 per year would appear to be ,mmewhat lower than the North American expe~ence. Table A10.2 Annual incidence ~te oE occupa~onal diseases in Poland, (pw :I Hesfing loss 20.5 In/ect~ous disease 14.7 ~t/voi~ p~ble~ 9~ ~m~o~is 8~ S~ d~a~ b.4 Hungar~ In Hungar~ attention has been foca..~.d on occupational health problems ~ ~e d~ of P~, at ~e M~ Um~ ~e ~d at ~e ~t~te ~e at M~ Mo~. Wor~ ~ ~g ~ at M~ ~ ~e hte 1 ~ ~ ~e ~e w~ Und~ noel o~g ~ndlfio~ ~e ~e ~ploy~ ~ ~ple (~sh at i~ ~ ~e ~e ~ploy~ n~y ~,~ workem): by 1~, 10,~ ~d ~ve ~e ~ ~ mo~ ~ ~ wor~S 1~ mon~ ~ ~e, ~tde ~m a~den~, ~ no~t~ h~S l~, s~, ~d I~g ~. ~ ~e ~ ~t o~n~, ~5 ~t of ~ work~ were develop~g ~t~ h~g pmbl~ ~ y~, whets ~ ~e ~te 19~, t~ ~d d~ ~ app~tely 0.5 y~ ~ ~e ~y y~ of ~e ~'s o~m~on, it t~k av~se of ~en y~ for ~ ~d~d d~op s~c~ ~m ~ ~ s~te ~t~ It ~ ~t by ~e ~te 19~ ~e avenge ~plo~ent ~ ~e d~e~pm~t of s~ ~d ~ appm~tely ~en~ y~. It ~ ~ ~ ~t • e~ ~d ~n 103 ~w !~S ~ ~ s~ 1981 ~ong the 10,4~ ~ple ~ ~ter ~n ~-five wor~ I~el mon~ of ~. ~e s~ ~d l~g ~n~ s~, when ~ken ~t~ as a ~te ~di~tor of ~e wor~S ~n~o~ ~ ~e ~e. H it ~ ~e d~o~ ~ ~ y~ of~t ~ ~ ~e ~ly y~ of o~on, ~en ~ d~ ~ ~ndi~o~ m~t ~ve ~ v~ ~ ~ ~ ~ a ve~ sho~ w~ to a~te ~ou~ s~ ~ ~e m~t~, ~t ~ ~ of w~t It ~sht m~ ~or ~ ~ ~y d~elop ~ a ~nt ~t~al of 20 y~ or ~ ~m ~e ~e of ~t ~ to ~ ~- ~o~ ~g~. ~ ~, ~e o~en ~s to wait d~. ~ ~e ~ of ~ ~ ~don ~s ~ a ~o~ 1~1, ap~tely ~ y~ ~ ~e ~e o~. ~t b o~ b ~t ~e wor~ ~n~eo~ ~ ~e ~iy y~ of ~e ~e ~ ~y d~e ~ ~t of ~e ~t !~S ~ ~d~. S~m ~e ~p~ ~ ~t~ ~ ~don gas ~ 107 BATCo document for Mayo Clinic 27 March 02
Page 118: 39000936
shaw up over the ne~t two dec~des will likely be ~y s~hted to the intensity of the expcma~ to silica in the em-ly yea:~ of the operation of the mine. It is lmpomible to dtct hmv many" new lunS c~ncer ~ might occur, wou/d not be surprisinS if it exceeded 1,000. If rids predic- tion is correct, it will create a part/curtly di~lcult health- ~ cr~is in a c~mmurdty htcinS the prmpect of mass unemployment w/th the potential shutdown of it~ two largest Indu~=tes. S~licosis w~s aL~o a rr~or probL-m ~mong the unde~- gnmnd miners in the antluacite urine due to the si~cat~ in the ~ in wh/ch the cc~ Ls found. In recent yea~, an aver- age wor~orce of 4100 miners have worked undergrmmd. Thes~ miners a~ allowed to do a maximum of 4,000 shi~ beam compulsory re~ir~nent horn undes~ound mining; which works out to be al~ox~nately 20 yea~ of experi- ence. Despite this max/mum, the m/ne is producing I00 to 120 new sificosis c~ses per year. ~ implies that the aver- age worker has approximately a 50 percent chanc~ devel- oping sillcosLs during Ida workinS ~e time. Cz~chosloc~. In Czechoslovakia, as in Hungary and Poland, routinely collected data on occupational di.~ases do not clearly indicate working conditions which are qual- itaclvely worse than in Western countries. In I~rge mea- su~0 thi~ may be the We state of affai~. But as due to the fact that ~uidellnes on compensabiJlty of dis- ~ are determined paLltical]y rather than scientifically; ~o direct comparison of compen.~at~on statistics from one coua~ry to another ~ be distorted by policy influences. Therefore, compen..~ation data are interast~nS mostly for identifying specific unusual phenomena rather than for making broad populaldon comparisons. in reviewing the compensation data for Czechoslovalda for the period 1978-88, ~wo items stand out. One is the per- si~tence of ~everal dozen ca~es of sificotube~dosis being compensated ~ year. This Is in add/tfon to appmx/mat~y eqml number of cases of non-~Llicotic type tubemxlmis which, presumably, come from the health c~re rector. These data l~.ely :~lect the ~ct t]~t tubemulmls is stroll endemic in C.zecho~lovzida, where~ in most Western coun~es it is sporadic. The second pertinent finding is that approxi- mately I00 ~ of lung cenc~ n~ted ~o exposure to Ion- Izat/on radiation are being compemated each year. This an extr~nely lmlmt~ant ~tcome becauae it mpsmenis an element of the public health con,,~..quence-, at exploiting nuclear en~%,y as :, substitute for cmL The~ have been studies of six Sroupe o/mine~ who work In umninn~ iron, and shale clay mines and are exlx~.d to radon gas, using world-cla~ cohort methodof ogy and sta~tical analysis. The ~tudF smuFs include one sub-cohort whose exposu~ began be(on~ 1950, thee wh/ch began in th~ l~.~0s, one in 19~, and the latest one in I~73. The result~ a~ pa~--ularly useful in estimat~nS an "attrib- utable tisk" Per unit of expasure; which is s/yen a~ 20 to ~0 lung cance~ per million per year per working level month of exposure. From these data, it is possible to make rough e~tin~tlom of the ongoing risks of continuing to mine ura- nium and other substrata (ound in wck w~th high radon levels. I~ ~he dose-response relat/omhiFs reported in the research t~lay still apply to the mining conditions of the early 19~, then a great de~ of knpmvement in the work- ins con~tions will need to n~de behyre the risks are in any sense "acce]~zble," even in a cotmta'y which must make difficult tz'ade-~ff~ in order to obf, xln enes~,~ As good as the work on radon exposed wcrke~ is, it is incomplee. It would b~ very impo~ant h~r studies to evalu- ate leukemia and other c~nc~s which ndsht be attributable to ionizing rad~tion ex'posun~. These studies would be essary in order to more COml~ehensively determine the heal~h impacts of obfainins energy from radioactive somces. Table AI0.3 Occupational var/atiom in the proportion of reported congenltal anomal/es in mininS districts of northern Bohemia Non.exposed 13,06~ $.~ Prtntln$ 16 25.0 .,.184 Halr-dreuslnS 61 11.5 4.31 Gas-production 63 I 1.1 A~rlculture 3~3 11.0 Chemical production 279 10.4 +18 Hospitat. S04 9.3 ÷11 Non-~tpm~:i 12.111 8.4 Printing 18 33.3 Gas*production91 14.3 +70 ~emical p~u~on ~9 11.7 +39 Mac~ne p~u~ ~ 10.3 MininS 1111 9.5 +13 M~fcal d~o~ 1~ 7.4 BATCo document for Mayo Clinic 27 March 02
Page 119: 39000936
The following tables provide some in/'or~nation ~,'~d- 1~ oo:upa~ona] variations in the pmlX~On ol ~qx~rt~ congenital ~oma~es among workers tn two cities among the mining dts~ct~ of north~'n Bohemia compa~d w~th the town of Jablonec in the non-mining d~trict of northern Bohemia. The former table shows thr~-fold variations Me propo~on of ~d~ ~th ~ng~ ~o~ ~ ~d ~ ~e ~pa~o~ where ~e s~t n~ ~d~n ~ve ~n ~m (Le. ~ong p~ten). How~, ~ m~olo~l ~bl~ sh~d not ~ ~t Se dm ~ ~ng, o~y ~t th~ ~ ol ~th~n~. ~e Repub~n Hyoene Cen~ ~t, ha~ on ~d~M by~ene mo~to~g, appmM- ~te~y 1~14 worke~ ~ 1989 we~ wor~g m~ where ~em R ~ ongo~g ~n~ a~ut to ~ ~ va~, d~t, ~b~on, or no~. ~M~s ~dus~ a~ co~tde~ to ~ tex~, ~c~- ~ I~, 373 ~s~ o~ ~pa~o~! d~a~ te~ ~ Lithua~, up ~m 2~ ~ 1989. S~.~en ~nt o~ ~ ~volv~ ~bra~on (p~y nol~ (p~a~y h~g loss ~ the tex~e, lum~ ~dus~es), and 7 ~ment ~volv~ ~e ~stem. ~ a ~ult of ~braHon pmble~ ~dth ~rly ~d~de s~ ~ among h~th ~ wor~ work~ p~u~g bu~d~g ~t~R, ~nd worke~ ~R at ~e Repub~n Hy~e C~ ~ For ~n~, no ~ ~ ]~d s~e~n~ R ~M out ~ d~~ ~d~ ~ w~ ~ld~g ~ done. ~ ~ H~e ~i~ ~n~fio~. V~b~ due to m~ ~c ~ R ~t ~¢at~ ~ the ~ ~t, wh~ ~t who was ~t~t~ ~ ~bmfi~-~tM bl~ ~ ~o~er ~mple, o~y 1-2 a~te ~fi~de ~. No one ~o~ ~w ~y I~ a~ ocs:ur. FL',.aU, y, there is no organized tnsur~ce fund ~r ~, ~t ~ m~t ~ ~d ~y ~ ~e ~ploy~. ~ p~[~. ~e ~bH~ Hyoene C~ ~id- ~. ~ ~ ~n to ~e ~t ~e mint si~- wor~ ~th~ ~n ~ ~e ~. As~dy ~M om ~ ~d a silent workp~ ex~ w~ 11~ ~ M~ ~ ~n~R who did not ~ve l~g ~. U~or- ~te]y, ~ work w~ don~ ~ I~5. ~d ~ ~t ~ ~t~ s~ce. Nor ~ve ~e~ ~n ~y mo~ d~M ~rkp~ ~ ~. ~tM ~t I~,~ work~, I~ ~t of the wor~o~, ~ wor~s ~d~ ~r ~ndl~o~, It ~ not d~r how ~ ~te was ~de. Mo~ ~n~y. ~ ~t of ~5 ~to~ ente~ ~ ~a do n~ m~t ~nt ~ ~ s~ndards. ~pite ~ m~t~, th~ we~ o~y ~ ~v~ t~ ~bu~on cfth~ d~. Table AlO.4 Most commonly ~.ported occupational diseases ~ ~ 1~ Lung ~nd b~nchial i~,~s ~.2 C~hleJr he,tides 33,1 Mu~losket~l & peflpher~} ne~ous 5yst~ 18,2 ~br~Uon-lnduc~ dlseas~ ~]e~c d~e~ 9.8 The nmnber of reported lung and bronchial diseases has been increasing in recent years, occm-~g most f~- quently among workers in the building materi~q industry, me~hanic:q engineering indusl~y and glass ~nd ~lu~t~. In 19~0 there were fourt~an ~ of nlOSLS (e.g. s~icos[~, asbestosls) diagnosed, mostly from the electrotechn]c~! industry. These figu~s am Likely to be gross underestimates. For example in Brecerd, polyd~i¢ ~'on:ls show that more tl~n 4~ asbestos cement workers a~e suffering from obstractive lung ~, yet no more than • handful of them l'~ve found thek way into the national st~tisties. Like Lith~nia, the lndtvtduzl work- place must pay some. though not ~ of the compensation to d.L~bled worker~. We am not s~ to what extent this cUsincent~ve has ~luced ~ccupational cfisease repo~,ing and to what e~tent underdia~'nosLs and poliHcal manIFu- lalJon l~ve been conlrtbut~S favors. B. n~l is the site of the '51ares' asbestos cement which has high levels of ambient asbestos in the work- morn air. Data show l~.iodic expesums to asbestus • .sl~estus-laden dust ranging ~m 2#. to ~.6 mtillg~tms per c~btc meter. These data are somewhat cti~lcuk to com. pare to Western norms, which e~e oRen ~ in los ltl:~s ~ unit volmne, or as weight ~ volu~e of eletron mtc~,scoplcall7 con~xn~l fibers. Yet i~ wou~d be l'~=,,o~ble to assume the~e m~.su~.-d con~.-ntratlons ~e 0 0 C~ ~J~ BATCo document for Mayo Clinic 27 March 02
Page 120: 39000936
pmpo~on of the worken in the p].mt a~ dia~m~l ~ a ~t~a~, w~ ~dud~ w~twewo~ ~y ~ o~ve l~g d~. ~t w~d ~ ~de dmt d~t d~ su~ ~ ~t~b. ~ b ~ ~y of ~e ~ X-rays done ~r ~t d~ ~ ~ n~ of ~h ~ou~ q~ to ~e ~ ~ of a d~t ~8 ~e fi~ y~ 1987-91, ~e avm~ p~ ~tely ~ ~ and ~e ~p~to~ ~ w~ ~- ~. S~ce the p~t b o~y 20 y~ old and ~e m~ ~t~t ~ for ~p~to~ ~ due to ~ epid~c ~e. It ~ ~Rant to ~e ~t, dm~m the v~ dust 1~ ~ the p~nt ~d a~t~ ~p~to~ mor- ~ncem by en~t or h~lth au~o~m ~ ~. Dat~ were ~ta~ by ~ly ~o~1 mea~ ~d do not ~m to ~ ~ th~ ~on o[ any o~ ~ ~ga. ~ en~en~ o~ w~ not ~ncem~ t~e plant o~y e~ S,~ to~ of dust ~r year general en~enL ~ 8eneral, ~nce~ a~ut ~s~ ~ the m~on am n~ as ~gh as ~ey d~e to ~ on the bas~ of the h~n heal~ ~ o~ ~t~ ~d the ex~s~ condi~o~ w~ch ~t ~ p~ C~e ~ the c~ of ~e ~n p~~ ~d~. It ~s ~o ~e fa~m, ~o~ ~ Bio~ and ~tb~ofa~, w~ch ~ of en~ heal~ ~t~t ~ ~th am ~t~ a f~ h~d~ ~e~ of ~. It ~ a~ of ~paHo~l health ~ ~ of ~e ~m- pl~ che~ of the~ p~u~on p~. an~n~r a~m w~ am ~lv~ ~oge~ one s~ ~v~Hp~on of wor~m ~, ~e ~C was ~c~ ~ 17-21 ~t of m~s~m~ for ~nol, ~pmpanol, ~nol, ~ene, ~ldehyde, di~oHde, or a~one. At a d~n~ of 12~1~ m~e~, 9 ~t of sho~-te~ ~ ~pl~ ex~ ~e ~C hyctmg~n chloride, or f~rn~dehyde in 19~0-88. In ride, ~dehyde, ~pm~nol, ph~L ~one, ~ o~de, ~c add ~d m~oD w~ me~ at five l~o~ ~ ~e ~, ~ mont~ a year for ~ y~m. It w~ m~ ~t 41 ~t of ~ ~mpl~ ~c~ the ~C- ~e wi~ ~uent ~ud~ toluene, fo~c add deHv- a~, va~o~ al~ho~, ~d ce~a~ ~nog~c su~ s~nc~ ~ as ~ene and ~fl~n~r agent. ~, the w~ water ~ ~th to~c ~d mu~g~c. It b ~at~ at ~e p~n~s ~a~ w~ch b ~ mete~ ~m to~. Ci~ ~wage and w~te ~m Blol~ al~ 8o ~to the la~. ~e [a~ ~ ~I pmble~ with the ~mpI~ ~ of sewage, dom~c dete~ent, ~d ~dus~al ~e~b it must ~t. ~e~ a~ probl~ ~i~ ~afin~ ne~ to~c ag~ t~u~ ~o~on, a~e d~ ~a~ of voh~e hyd~r~, and conta~flon ~d~ater ~th ~c slud~, in add ilion, the plant h~ ~n b~g ~Hd ~asle ~ 12~ m~er d~p dolo~te de~i~. It b s~ t~t ~e~ ~ve con~ai~ the ~dwat~, ~t tbe~ d~ not ~m to ~ ~Bable on t~ ~. ~e p~a~H~l worke~ ~nd the town's inhabR- ~ts ~ve ~n the subj~ o~ health conce~ [or ~ve~l yea~. ~e most imp~sive o~ the~ involv~ worke~ ~m Eiolar, r~iden~ of Ola[ne, and controls ~m ~e. Results are sho~n in the ~ble below. ~ey sho~ that the worke~ and, ~o a lesser extent, the den~ ol O]aine, di~er ~m the controls on ~our impor- tant ~munolo~cal measu~. Also, it was demon- s~at~ t~t ~idents and workers had hisher rates bron~ifls and allergic r~nitis t~n cont~Is. ~e work- e~, but not ~e ~iden~, al~ had hi~her rat~ o~ c~c hepa~t~ and a[ler~c de~a~ than the co~ ~k. ~e ~ul~ a~ reasonably cr~ible b~use they are s~c ~o ~e to~c p~pe~ o~ the exposur~ ~om ~e plants. Bulgar. ~e foEo~ da~ sho~s ~e db~bu~on ~m~ ~o~I d~a~ ~ B~ for ~e ~t arable y~, I~. ~e t~ pm~o~I dls~bu~on o~ the ~m~ able ~ k ~ible ~gh, the ~ n~ of new ~ we ~d ~ve ex~ ~ a co~ of 8 ~on ~ple. Table A10..S A]lers]c and immunolostc~1 obse~stions in Olalne, l~tvis: pzmons working at chemlc~l fact~de~, resldenlm, ~d controls (percr~t*F) 0 0 C~ CO BATCo document for Mayo Clinic 27 March 02
Page 121: 39000936
Table A10.fi Distribution of compensated o~'upatlon~l diseases in Bulgaria, 19~9 I, RepefiHon Strain Injuries 49 3. Vibrstion Syndromes 4. Lun~ Diseases I1 5. ~oiJo~n~ 8 6. ~S~n 4 7. BJological fa~o~-i~on 3 When corffTonted with this ob~rvation, there seemed to be general agreement that, indeed, there was large scale undercountinS of occupational diseas~ in the conn.. A number of reasons were adwnced for this pmbiem. In order for an occupatloual disease to be compen~ted, it must be acknowledged by an expert diagno~ic conun/s- sion. These commissions, made up of ~'cupafional pathol- ogists, intern~sta, hygienists, and other speclallsta, exist ~0 locations ainu.rid the cou.nt~'y. Workers must apply to these commissions in order to set a disease compensated. It is thought that many physicians do not refer people to them who have legitimate occupational dLsease (e.g. noise lnduc~ hearing loss) and the network of commissions does not have any method to £md indi~duals who are not being ~fer~cl by thei~ physicians. If a worker is deemed by the comm/ssion to have an occupational disease, he or she s~l has to take the company to court in order to Set compensation. This is a surprising obstacle not found ~n other Eastern European coun~es or in North America. W~xen compensation comes, the payment is usually much lower than what the worker would make 1~ he or she were still at work. It would appear that there is no prov~ton m~de that would allow a worker to continue to work while coLlec~ing a dL~bility pension. in addition to an extended discussion on the problems on workers compen.~tion star, tics, We were ~iven gone- ral de~Tiptions of several investigations being carried out by' the Clin/c of Occupational Diseases. Most of this work does not contribute a great deal to our u~dm'standing of the envkonmental health situation in B~Igari~ because it deals with special surveRl,~nce and sc~erdng prog'r~'~s for workers, nther than health outcomes per se. We rece/ved one useful set of data from occupational surveillance which provided average bioed lead levels on worke~ from several plan~ in 1979 and 1990. It shows that the average blood lead levels were at or above the critlcal range of 40 to 60 micros-rams per deciI/ter ~or adults. Because these values are averages and not pesk values, we must assume that = large fraction o~ the workers in these ~cil/ties are being grossly overexposed to lesd. This the only data set available to me which helped d~on- strafe the potent~I scale ~or occupeflon~1 disease in BUl- ~ industry. It stands in marked confer.st to the mes- sage implicit in the compensation statisticz. U/traits. Like several other ccn~n~es in the Region, there appears to be sisni~cant under-reporting of occups- tional disease in U1craine. For example, in the indnstrl~l ~ity of Ivi~iupo], with a 1990 population of app~xi~tely ~0,000, there were only ll9 reported c~es oral] occupa- Ik~u] di..~eases over the paled 1980-91. The reeons flds are similm" to other coun~es ~ well. Uncler the l~revl- ous regime, physicians and plant n,.znager~ we~ dlscour- aged from diagnoslnS and rel~rtinS occupational dis- e~es. The I/st of compen~ble occupation~l ~ is limited, prknarily to: ch~nic dust bronchil~, pneumoco- rdosis, vlbrat~on-as~ted disorders, noise-induced he~r- ing lo~s, and certain back and joint condition~. Thes~ is • lack of aFprol~'i*te sc~-e~g and diagnostic tests. Despite extensive ex-posuro to lead in the worLThce, there are few facilities for testing for blood lead. For Instance, at the lead and zinc smelter in Konstantinovha, only ~5 ca.%~ of lead poisoning were re~orted between 19K5 and 1~O among a work~orce of approximately 1~0. Although annual physical examinations are done on the worke~, no propex blood semples m'e draw~ for an~lysls. Airborne lead levels in the smelter are exceedingly high. Between 1989 and ~992 the range of mean aL-bome lead levels in various work stations was 80-750 n~crogran~ Per cubi~ meter (the Ukrainian MAC is 10 micrograms per cubic meter and the American Permlsslbie ~ Limit is 50 adcro~'arns per cubic meter). ~ on the ex]:~- ence of airl~orne exposuses like th~ in other loc:,tions, it must be ingerred ~'~t there is massive under-diagnosis of acute and chronic lead poJsonlng in the smelter. Notwlths~,acllng these pn~olems, some significant occu- pational health l~obiems can be idont~ed through ro~- lent ~ of coal workers' pnenmoconiceis and chronic dust bronckit~s in Donetsk Oblast, which is home to approx- imately ~00,000 nnderSronnd co~ miner~. There ~re other, more ~ indications tl~t the cc~d m/nes n~y be spec~ally hos~e working envin~nmenis. Undid coal mlne~ who work strenuously in a hot environment have increased nttes of acute myocard~l ir~a.,~on (he,~rt attack), which h~ been atm'buted by researchers to hot adcroclimates in the n'~Ines (o~ten with tempe~tores •t 35 de~ees Celsius) and arduous physical work. The r~te o~ sudden death • mons a~l miners in Donetsk Obiast is 170 per 100,000 per year (a tot~l of 510 sudden deaths a yem- among coal mlne~s in the oblast), as compared with a rate of 120 per ]00,000 per year among the rest o~the population. In UkntLne, many coal mines l~ve ve~cal sl~P~, l~tes of occupational dlse•se and injury a~ higher In mines with vertic~l sl~-ts than th0~e with hor/zon~ sha~. Co~ dust leveJ~ ~e ~/d to =vera~e ~0-150 mill/stores per cubic meter in the horlzont~ sh,~ts and :.bout 400-,q00 srmns per cubic meter in the vertlceJ sh,~ts. The rate of" vibratiou-assuclated di.~rdera is more ~ ~teen t~,mes h/gl~er in mines with vertical sl~s than thcoe with hod- zontal sh,~ts. In •ddition, there have been d~nsmented instances of cha~icaLs ~ch as chlorobenzene, forms~e- hyde, and cyan/des dkect/y leaking into mines with verti. ca[ ~ h'om ~ctor/es that sit atop or near the top o~ the mine sl~fts. In one incident, three deaths occurred when chlorobe~zene had been al/owed to le~k into ~ vertlca/ mine el~-t over mt le,~t several weeks, despite fn~n • fl, ctor7 that was ]ocsted at the top of the mine. Bdarus. Furthm" evidence of und erore.porl~ng of occup~. tional disease comes kom Belzrus, where, in the most 111 BATCo document for Mayo Clinic 27 March 02
Page 122: 39000936
t~on~l dL~bi]Jty because n'ar, agement has ~ ~m~ ~ ~ ~ B~ ~e wor~ ~ ~ ~ ~d~o ~~y ~b~ ~e ~t one ~ done at ~ p~nt ~ a ph~ ~ ~r ~ ~g~t, ~e ~ond d~ ~ ~ o~ ~, ~ ~e ~ one ~ done a ~ at ~e R~b~ Cen~ at ~ ~em ~ ~ of a~mp~ d~m~ ~t at ~ leveh ~d 0 0 Oo OO Oo O0 BATCo document for Mayo Clinic 27 March 02
Page 123: 39000936
Bibliography Andm~on, T. W. 1992. ~u, ~. I~ H~." World ~, D ~ 3~. ~ 13 (3): ~5. 11.1 BATCo document for Mayo Clinic 27 March 02
Page 124: 39000936
H~ ~ ~ {4): ~. ~ ~ ~ ~y~ ~ ~ Gym ~~ H~ 131 (1o): 51~517. ~ ~ O~~ 41: I~I~. ~ 4: (3) ~~Po~'~t~~l~ ~1~1~. ~ ~ 111-119. BATCo document for Mayo Clinic 27 March 02
Page 125: 39000936
in Worlms Occupaeomlly F.~Fo~d t~ r'onmldeh~l~." ~w~ek. J., G. ~e. 1981. lmmu~lo~ ~ (4): ~7~13. ~." ~I ~¢~ a~ M~[~ 16 (4): ~t 4A. C~ ~ He~ ~D}. C~ f~ H~ ~ ~d P~ ~v~, Bd~h Col~. ~sion P~ ~ ~ ~0D). ~ Po~ Rm~ V~uv~, B~h C~. ~ ~ A~ut ~e ~ ~te for Adv~ R~ F~on P~ S. C~m for He~ ~d~ ~d Po~ ~ion Pa~r ~ ~ (2D). C~ ~r H~ ~I Po~u~on." He~ PoB~ R~ U~t ~ 91 (SD). C~ for H~th V~couv~, BH~sh ~ Gap? ~ ~ lot Adv~ ~ H~th ~r~g Pa~ 16. ~ I~2 (c). ~n~t ~d H~ (3D). C~ for H~I~ ~ ~d PoU~ ~ V~- ~, gd~h Col~bla. ~. D. ~d G. ~y~L ~s. 1~. ~d C~n Study ~ ~,~n. To,o: ~. H~L D. ~., D. L Da~, g B. ~, ~ J. ~n~ ~ J. ~. ~): Ho~, g, M. Su~d~, D. Pa~, ~ ~ "A ~ Fon~bb l~ S~y~ ~k 111-I~. H~a~ ~, ~ S~v~, B. V~ ~ ~I. I~. l~duct/on and l~mve~ P/~nt/n ~ w/th Fal/en l~t)." E1,~nul, ha~ay 3I 0'a~uary 24): 166-178. Hr/honm~ D. 1992. "~viro~nen~l Hmlth in UIa~e." V~id gmk (Cc~w/D~,panm~t IV, Na~r~ ~ ~ ~en~ Div'~n), W~,hln~,ton, D.C. EnvL, oz~enml Health Prc~ School of Pub~ Hmlth, Unl- Eughes, G. 1991. "Are the Co~t~ o! CT~:~.~g up ~ Europe F.og~a~ed? Ec:onomlc Reform and the F, cwtwnmmt." World Bank, Europe and C~-al A~ia, M~ddle E~ and North Africa Regtons, E~vtnmmmt Division, Wuhlng, t~ D.C. /-Iivatal). I~. "An Eeolo~.al S~udy ~ Mort~ty in Budapest, 1980-t9~1, P~ L" ~a~ical Publl~h~ Houae l~pon~lble ~" Publication. Budapest. I~vatal). 1989. D~w~/~ E~,nyu ~ssa. ._.__. 19~7. SPtls~R:al Ymrfoo~. H~lth ~ Sy~n: ~,ues and Opt/on~ ~r ~,~" auci~p- e~t, Hungar~ Ti~ l~t. 199~ (a). "EC Tobscco Subsid), 'C.mzy." V. 2~ (O~o1~'): L T~lnA, pen~. 1991 (b). "How'900 M.Igfon Pound~ o~EC Mont7 Goes Up In Smoke." V. 25 (Octol~'): 21. /ndubld~ J, A., N. Szesz, en~-Dabrow~, Z. Szube~t. 1968. nm ~ Accide~t-~lat~d A~tt,d~m ~ Poland belween Con~u~t[ng, 1992. ~ P~ 5~les~: Comparative ~c~Lng An~ly~i~." Faper Fr~ for the Tec~m/c~J Work- Hop, Ost~w, Czech l~ubUc. C,~mbddge, Insi~m~e of Health L'~ormal~on ~,nd Sul~atlc~. 1990. Hm/~h C~n~ ~ He~l~h Serv~ in ~ P, el~blic in S~r~;~,l ~.. Pr~&ue. L~l:itute o~ HyBlene. 1989. "De~rada~on ~ EnvL'onment in Pohmd." Wm~w. Jac,/~Tn, K. ~nd W. Lesiecld. 1979. "Low Leve~ ~ of Niero- g~ Oxides Ezn/tted by Power,~a~/on~." I~rn~/ ~ ~ ~r~ Health AI4 (6): Jedrychow~kl, W. ~nd M. Krzy~ow~kL 198R "Venti~tory Lung Pmlction ~nd Clmani¢ Chest Syznpton'm Among the l~abit- • n~ c~ Url:~n Are~ with Vadou~ Lev~ of Acld A~o~oh: Pz~pec~ve Study in Cr,~ow." En~rvnmm~] Hmlth ~ ~9:101-I07. Jozan, R 1989. "R~ent Mo~dlty "/~e~.s la E~tm'n Eu.n~e." World 'me ThL, d ,~ o~ El~d~miolosic Tra~it~n and ~he Health __. 1989. "A Completion o~ 5ome A~pec~ o~ A~es DLr~entia~ In Some E~ Co~m~e~° In Fox, J. ~'~'~'~'~'~'~'~'~ - P 0 L ~ June 1989). Wu~o~ D,C 113 BATCo document for Mayo Clinic 27 March 02
Page 126: 39000936
Levy, B, S., and C Levm~ein (ecb). 1~90. "E~v~ronmmt ~. UN~ ~t~ E~ ~p hr ~pdo~ ~o~, I~6. ~ ~ ot B~e R~ Workm • e UN~ ~." ~ ~,~ S~ ]~1 # ~i~ ~ (3): ~-218. ~m~, ].R, M. ~ ~0~e, • J~. l~. "Avoid- abld Mo~ ~d H~ ~ A R~ O~ A~te ~, E, ~ Ku~ g ~L 1~. ~e ~d~ I ~: ~ Con~Uon ~ Work" Int~t~ l~i ~ 1~ (4): ~74. a~ ~il ~ 26: D~ N~ ~ ~e Po~on ~S ~d Oem~yl." lou~l 12 (3}: 41~. Na~, D. i~ ~1~ a~ H~I U# Ta~ 1921-198I ~w ~d ~ ~ ~d." Annul ~ ~ Publ~ Hmtlh ~ Enable," PSRQ 2 (3): ~ ~Be Nae~ ~ ~d R~ ~ the ~1~-~ C. 1989. ~ ~ Poh~ in 1~86. W~wa. ¢o~d. BATCo document for Mayo Clinic 27 March 02
Page 127: 39000936
Oatado Hydro. 19~0. "Mrcmkl O~ ~ ~r=tt,~i= ~ 1~ ~). OECD En~ ~M ~ium ~. B. 1~4. =~g ~ H~ ~ of~ ~u~: A M~h~ ~th an AppIJ~fion ~ J~." ~og~ ~r~ng pa~r 1~i. World ~ Po~ ~ Pal~, ]. 1~2. ~ad R~ C~ A~ ~ ~c Cancer Indd~ce as S~di~ ~ a R~ ~ Palu~va, O., M. U~yov=, R Tm~, ]. ~. l~. ~ M~ pR~ for ~e ~ ~te~o~] T~ ~t ~g87. Wa~wa, ~oland. mental Con~afion ~ Mu~g~¢ ~nd ~c s~nco ~ the ~ of the ~ P~ P~t, J. ~1. "Health ~ - = $pma~8 $i~." ~ ~t ~uly 6): ~1 & ~h, L 1970. ~e~m ~t~ ~ l=dt-~d F~l~hfitlt d~ Medizin ~ (12): 51~516. ~. 1985. ~dc~g yon ~d~ ~ 8~i~en." ~d~c~ aus ~z~l~t~ in Pr~ u~ ~iaK 7 (3t: 12~31. Pdlefier, g R., D. L. H~g. 19~. ~sy~oa~ol~: Towa~ a Mind ~y M~d." ~mnc~ 5 fl): ~lips, L 19~. "B~aby Mo~ ~bi~t Hy~r~ ~ PoBu~on Con~l. B~aby, ~da. n~ N~o~v v $5R. V~a ~davateb~ Slo~ Vi~. B~ffslava. Slov~ R~ub~c. F~, C. A. 1~9. "R~p~ato~ ~ M~t~ ~ Co~u- /ou~l ~ Public H~lth ~ (5): 6~28. d~n." Am~n ~ ~ ~a~ ~ ~ 145 {5): Po~. C.A., J. ~hwa~, M. • ~. 1~2. ~y M~ Hmlth 47 O): 211-217. Po~r, C, O. M~r, A. J. Fox, ~ F~e~. 1~. ~ton, S. 1976. Mo~li~ Patt~ in Nati~l P~bt~, ~th $~- Prms. ~d~t ~= ~w. ~989. InCa o SMn~ Po~n~ 117 BATCo document for Mayo Clinic 27 March 02
Page 128: 39000936
monphce Construction Activities." Department of Pmveneve Medicine and 8tostatistics, Univev~iy of Toronto and Re, earth and Developraent Depamnent, Construction $alety As.sociation of Ontario. Sapolsky, R M. 1990. ~tres~ in the t~r~Id." Scienh'~ Ame~i~n 262 {I): 116-123. Sarkany, IL. O. Kekesl, R Rud,nai, R Pasztt.rnak D. Pa~ty. 1989. "Dasan~os halalozasi terkep ~ Budape~ti k~rul~elon 1979- "Growth and Bone Maturation In C~d~e~ h~m Two P,e~on~ ~f the Federal Republ~," of Germany Differin~ in ~e De~ee of Ah" Pollution: Resul~s of ~e 1974 and 1984 Surveys. ~o~r~! 358. Ph~delphia Assoc~ted with ~ Air Pollution Concen~- tions." Amer/c~n ~ of P, eq~/mtory ~ 145 (3): 600-604. • 1992. "Particulate Air Pollution and Daily Mortal/ty in Stenbenvi/le, Ohio." American Journal of Epidemlology 135 (I): 12-19. Epstein, D. D. WeLkart 19~. "F~fec~ of the Perry Pre~honl Program on Youths Through Age 19: A Summa,-y." To;~s Early Childhood Spedal Education Qu~rferly 5 (2h 26-~5. Seroka0 W., M. l~owski. 1%4. "Daily "¢isl~ to a General Practitioner and air Pollution." Pn.t$1~d/.z/~r-A'/41 (6): 433- 4,:17. Sevc, J., E. Kunz, V. Placek. 1988. "Lung Cancer/n Uranium Mines and Long-term Exposure to Radon Daughter Products." Health Physics 30 (June): 433-437. Sew, |., E. Kunz, L. Toma sek, V. Placek, I. Horacek. 19/~. "Cance~ in Man A~er Expcswe m Radon Daughters." He~lth Physics 54 (1):27.46. Shannon. H., C. Hertzman, J. Julian, M. Hayes. 1988. "Lugs Can- cer and Air Pollution in an Indus~al City:. A Geographical Analysis." C, anad~an Journal of Public Htallh 79 (4): 255-259. 5hotyk, W. 1993. "Poisoned Water, Poisoned Air." T~ Globe and M~II January 29: A17. 5ilia, g 1991. "The Influence of Environmental Pollution on the Cl~dran's Htalth in North.~st Estonia." Paper p~,~ted at the Confe~nce on Development and Health of Estonian Youth, Talllnno Estonia. ~tstitute of Pi'eventive Medicine. Smith, G. D. and M.J. Shipley. 1991. "Con/oundin~ oIOccupatioa and Smoking: Its Magni[ude and Con,sequences." Sodal ~nce and Medicine 32 (11): 1297-1300. Smith, G. D., M. J. Shipley, M. G. Marmot, G. Rose. 1992. 'q~lasma Cholesterol Concennation and Mortality." ]ourr~l of~b~ Amcr- /can Medi~.! Assx/~t[on 267 (1): 70.76. Smith, G. D. and !. Pekkanen. 1991. "Should Them be a Morato- rium on the Use of Cholesterol Lowering DrugsF" British Medical Journal 304 {6824): 431.4~4. 5tarzewska. A., and B. "A~Tniak. 1991. "F, nvimnmtmt and Health in Poland." Paper presented at the ~rkshop on 1"he European Charter on Enrichment and HeAth in the Baltic CounU'ies, Stockholm, Sweden, Novemer 25-28. World Health Ch'ganlzation, Regional Office ~r Europe, Copenhasen. Statistics Canada. 1989. "The Leadin~ Causes o~ Death at ~ ent Ages." Health P, ep~s 2[989 3 (1): 3-4. ~ 1989. "Mortality: $umma~ List of Causes 1987. Rrpo~s 19891 (I): I0-11. .qyme, S. L 1991. "Control and He~Jth: A l'e~,,o~d Pe~l~.~ve." A~ven~e~ 7 (2): ~6.-27. Szabuka, M., 7_ [van).t. 5. Fe't~, L 5zente,~i, A. Czeizd. 1980. "A Komyezed O]omszennuye:zodes Es A Rep~:luO~o: ~.es~,..'y 61: 4~-qL Technolc87 Devdopmesl~ ~nd Technk~ Se~dces Brand~ 19~ N~I Air PNIuI~ ~,~7~ ~,~ $~ ~ ]98~. of ~e He~ C~on of ~ ~id~t ~ ~e ~d~ ~ S~e Che~ ~ ~ ~t~." Pa~ p~l~ at ~e ~, ~m~ ~te of ~ve M~. T~. ~ g ~n~, M. ~ ~ al. I~I. ~ of ~ at ~ Coerce on ~dopment ~d Health ~ B. I~ ~ ~d ~nt ~ J~ ~ Hy~. E~iolo~, Mi~ol~ ~ lmmuno~ To~k, ~., g ~, M. ~n~ ~ ¢1. 1987. "A~i ~ Pa~ g~a~. (Mu~g~ ~ A~ ~d Papa due to ~ssio~ ~m ~e~e of Chlo~t~ Xe~bl~ In the ~e En~mnm~t." ~1~ Hy~ 29 (6): ~316. HexachIo~e R~du~ ~ ~e F~ Cha~." h g ~d I. g R Cabral (~) P~dinss ~ an I~tio~l S~ium, ]nte~o~ Agen~ for R~h on Onc~ ~- ~c ~blica~o~ ~. Ly~ ~tema~n~ AgenW R~ on C~c~. ~ J., A. ~p~l, L Pa~, V. Sku~va. 1989. "~v~figa~ons the ~ad and Cad~um Cont~t of V~e~bl~ in the $invak ~a~t R~ubHc." ~s~ Hyg~ M riO): 5~-~. Io~ng P~Hdde R~idu~ ~ ~e ~ ~ the 51ov~ R~bHc," C~l~s~ H~ ~ (5): ~315. ~ J., M. ~m~ M, R Ru~ova, J, ~¢. 1989. ~on of ~e Nitre aM NiXie Content o~ V~etabl~ ~ the v~ ~t Republic. C~I~ Hys~ M (9~ 51~5D. H~I~ o[ ~e R~bHc of ~t~ia. Tal~ U~h, g 19~. "~ Po~omu Pd~tkow Shdo~ch S~no~ ~e ~e Dh ~a w Gleba~ Poh~ N~n~h Na ~z~enie (An Evalua- ~, Pol~. U~ Na~. V~ yea~. ~phi¢ Ym~. New Yor~ ~ 1~. ~o~ Y~ Hbt~ Su~l~t. New Yorg ~ 1~ ~ ~ ~s ~M~ali~ Si~ 19~. N~ YorL ~ ~ World H~ ~n. 1~ Ur~n A~ Pollution ~d Hea[~ ~ ~m Eu~" In B. $. ~. and C ~- ~, ~s. ~cu~t~l a~ En~tal H~lth Du~ng 0 BATCo document for Mayo Clinic 27 March 02
Page 129: 39000936
.r~tn~e E~change [~ Occupa~onal and A~r Qulity Cri~ ~r Pa~u~e ~1~ fl952). ~A~/~/020F ~. ~ ~e ~h P~ and ~ Study R~." No~ R~nal ~ Heath ~ R~ Co~on. U~. ~A O~ d ~a~ ~ ~elopm~t ~d Vag~, D.. O. Lund~. 1989. ~th ~e~ Sw~" ~n~ 2 (~S3~ ~. Valkonen, T., J. ~s, ~ Z~d~. I~L • e ~tema~o~ Co~fion ~ F~ Tnde U~, Hea~7 Metals ~ ~e ~tr d Po~fi~ ~opment and Health of~m~n Y~, T~ ~. ~sfi~te of ~v~five M~i~e. nia." Pt~ p~t~ at the al the Co~ meat and Health of Esto~ Y~th, T~, ~. ~ ~'enfive M~ne. ~n IHD ~sk Facton and ~u~o~! ~w PoI-MONICA ~pult~on." ~, ~Ep~i~ ~ de ~nee Publ~ue 38 (5~): ~1-~. Wal~, M. D. 1~. ~ot~ Ve~cle Po~u~on ~y lot ~s." ~e World ~. Was~on, D. C. Wam~, ~ ~ and ~ S. S~th. 198Z Vuf~able litudi~l 5ludy ~ ~ilimf ~ildr~ ~v~, N. E and ~ L ~n. 1~. ~ U~ ~ ~e ~d~ ~ A Health Pm~ve." Am~n l~ust~l alton Io~ ~ (6): ~7. ~ P,. G, I~2. "Income Dism'butlon aacy," Brltish Me~Ictl loun~_ 30t W~ld Bank. 1990. ~8~ ~mt S~ ~d~ ~- ~ld ~ 1~I ~). ~e ~ ~ ~o~ ~ ~, ~Id~ I~ ~). ~~~a~ ~ W~ D.C, W~ D.~ ~. 1~ ~). ~e ~0 MO~ ~ A ~ld~de M~- ~t~ti~ ~11989. ~a. York ~ U~v~l~ ~. ~ 197~979. N~ Yor~ S~V~g. ...... L _ BATCo document for Mayo Clinic 27 March 02
Page 130: 39000936
gO qoJei/~i LZ~ o!u!!o o~el~i Jo~ ~,uau.znoop oO.LV8
Page 131: 39000936