European Health Report

European Health Report
The WHO Regional Office
for Europe
A synthesis of evidence and analyses from WHO and other sources, the report
identifies both noncommunicable diseases as the main cause of the burden
of disease on the Region, and communicable diseases as an additional
burden on eastern countries, caused by poverty and underfunded health
services. It shows that using well-known, comprehensive interventions
to tackle the leading risk factors – tobacco, alcohol, high blood pressure,
high cholesterol, overweight, low fruit and vegetable intake, and physical
inactivity – would largely prevent the leading conditions – ischaemic heart
disease, unipolar depressive disorders, cerebrovascular disease, alcohol-use
disorders, chronic pulmonary disease, lung cancer and road traffic injury.
This creates a compelling argument for action.
Member States
Albania
Andorra
Armenia
Austria
Azerbaijan
Belarus
Belgium
Bosnia and Herzegovina
Bulgaria
Croatia
Cyprus
Czech Republic
Denmark
Estonia
Finland
France
Georgia
Germany
Greece
Hungary
Iceland
Ireland
Israel
Italy
Kazakhstan
Kyrgyzstan
Latvia
Lithuania
Luxembourg
Malta
Monaco
Netherlands
Norway
Poland
Portugal
Republic of Moldova
Romania
Russian Federation
San Marino
Serbia and Montenegro
Slovakia
Slovenia
Spain
Sweden
Switzerland
Tajikistan
The former Yugoslav
Republic of Macedonia
Turkey
Turkmenistan
Ukraine
United Kingdom
Uzbekistan
The European health report 2005 has a special focus on children’s health,
because health in childhood determines health throughout life and into
the next generation. It reveals differences between the patterns of ill
health in children and in adults, and wide differences in the causes and
rates of illness and death in children across the Region. This shows the need
for complementary policies on adults and children and the complexity
of the task countries face in working to improve children’s health. While
recognizing that each country must chart its own course, the report identifies
poverty and socioeconomic inequality as the greatest threats to children’s
health, calls for renewed effort in protection and promotion, and provides an
evidence-based list of the characteristics of the most successful policies and
programmes. Investing in children’s health is investing in the future.
World Health Organization
Regional Office for Europe
Scherfigsvej 8, DK-2100 Copenhagen Ø, Denmark
Tel.: +45 39 17 17 17. Fax: +45 39 17 18 18.
E-mail: [email protected]
Web site: www.euro.who.int
The World Health Organization
(WHO) is a specialized agency
of the United Nations created
in 1948 with the primary
responsibility for international
health matters and public
health. The WHO Regional Office
for Europe is one of six regional
offices throughout the world,
each with its own programme
geared to the particular health
conditions of the countries it
serves.
The European health report 2005. Public health action for healthier children and populations
Governments and policy-makers in the WHO European Region know that
good health is a fundamental resource for social and economic development.
While rightly proud of the overall improvement in health in the Region, they
still face a widening gap between the western and eastern countries in the
Region and between socioeconomic groups in countries. Reducing these
inequalities is increasingly vital. The European health report 2005 shows
that it is also feasible. The report summarizes the major public health issues
facing the Region, particularly its children, and describes effective policy
responses. This helps to supply the reliable, evidence-based information
needed for sound decision-making on public health.
The European
health report 2005
Public health action
for healthier children
and populations
The World Health Organization was established in 1948 as the specialized agency of the United
Nations responsible for directing and coordinating authority for international health matters
and public health. One of WHO’s constitutional functions is to provide objective and reliable
information and advice in the field of human health. It fulfils this responsibility in part through
its publications programmes, seeking to help countries make policies that benefit public health
and address their most pressing public health concerns.
The WHO Regional Office for Europe is one of six regional offices throughout the world,
each with its own programme geared to the particular health problems of the countries it serves.
The European Region embraces some 870 million people living in an area stretching from
the Arctic Ocean in the north and the Mediterranean Sea in the south and from the Atlantic
Ocean in the west to the Pacific Ocean in the east. The European programme of WHO supports
all countries in the Region in developing and sustaining their own health policies, systems
and programmes; preventing and overcoming threats to health; preparing for future health
challenges; and advocating and implementing public health activities.
To ensure the widest possible availability of authoritative information and guidance on health
matters, WHO secures broad international distribution of its publications and encourages their
translation and adaptation. By helping to promote and protect health and prevent and control
disease, WHO’s books contribute to achieving the Organization’s principal objective – the
attainment by all people of the highest possible level of health.
The European
health report 2005
Public health action
for healthier children
and populations
WHO Library Cataloguing in Publication Data
The European health report 2005 : public health action for healthier children and
populations.
1. Health status 2. Health status indicators 3. Child welfare 4. Risk factors 5.
Socioeconomic factors 6. Mortality - statistics. 7. Morbidity - statistics 8. Health policy
9. Policy making 10. Comparative study 11. Europe
ISBN 92 890 1376 1
(NLM Classification: WA 900)
ISBN 92-890-1376-1
Address requests about publications of the WHO Regional Office to:
• by e-mail
[email protected] (for copies of publications)
[email protected] (for permission to reproduce them)
[email protected] (for permission to translate them)
• by post
Publications
WHO Regional Office for Europe
Scherfigsvej 8
DK-2100 Copenhagen Ø, Denmark
© World Health Organization 2005
All rights reserved. The Regional Office for Europe of the World Health Organization
welcomes requests for permission to reproduce or translate its publications, in part or in
full.
The designations employed and the presentation of the material in this publication
do not imply the expression of any opinion whatsoever on the part of the World Health
Organization concerning the legal status of any country, territory, city or area or of its
authorities, or concerning the delimitation of its frontiers or boundaries. Where the
designation “country or area” appears in the headings of tables, it covers countries,
territories, cities, or areas. Dotted lines on maps represent approximate border lines for
which there may not yet be full agreement.
The mention of specific companies or of certain manufacturers’ products does not
imply that they are endorsed or recommended by the World Health Organization in
preference to others of a similar nature that are not mentioned. Errors and omissions
excepted, the names of proprietary products are distinguished by initial capital letters.
The World Health Organization does not warrant that the information contained in
this publication is complete and correct and shall not be liable for any damages incurred
as a result of its use. The views expressed by authors or editors do not necessarily represent
the decisions or the stated policy of the World Health Organization.
Book design: Sven Lund
Printed in Denmark
CONTENTS
Abbreviations
vi
Foreword: putting knowledge at the service of a healthier future
vii
Executive summary
Part 1. Introduction
Introduction
Conceptual framework of the report
References
viii
1
2
4
8
Part 2. The general public health perspective
Overview
Major causes of the burden of disease
Major preventable risk factors
References
9
10
21
30
39
Part 3. Child and adolescent health and development
Rationale for the focus on children
Major causes of the burden of disease
Children’s health determinants and policy responses
Main factors in successful implementation of policies and interventions
References
45
46
51
66
78
82
Annex. Statistical tables
Note on estimates of the burden of disease in countries
89
90
Table 1. Population of the WHO European Region, 1990 to 2015 (projected)
91
Table 2. Basic public health indicators in the WHO European Region
92
Table 3. Level and distribution of income in the WHO European Region
94
Table 4. Deaths and DALYs attributable to the 10 leading causes
in the WHO European Region, 2002
95
Table 5. Shares of total deaths and DALYs attributable to 10 leading
risk factors in the WHO European Region, 2002
108
Table 6. Basic indicators of the status and determinants of child health
in the WHO European Region, 2002 or latest available year
119
Table 7. Burden of disease from seven leading conditions in children aged
0–14 years (DALYs per 1000) in the WHO European Region, 2002
122
Definitions of the indicators included in the tables
123
VI
T H E E U R O P E A N H E A LT H R E P O R T 2 0 0 5
Abbreviations
Organizations, other entities and activities
CHILD
CIS
DOTS
EU
Eur-A
Child Health Indicators of Life and Development (project)
Commonwealth of Independent States
directly observed treatment, short-course (strategy for tuberculosis control)
European Union
27 countries in the WHO European Region with very low mortality
in both children and adults
Eur-B
16 countries in the WHO European Region with low mortality
in both children and adults
Eur-C
9 countries in the WHO European Region with low child mortality
and high adult mortality
FCTC
WHO Framework Convention on Tobacco Control
HBSC
Health Behaviour in School-aged Children (study)
IMCI
Integrated Management of Childhood Illness (strategy)
MONICA multinational monitoring of trends and determinants
in cardiovascular disease project
UNAIDS Joint United Nations Programme on HIV/AIDS
UNICEF United Nations Children’s Fund
Technical terms
BMI
CVD
DALYs
GDP
GNI
HAART
HALE
IDD
MDR-TB
NCDs
SARS
TB
YLL
body mass index
cardiovascular diseases
disability-adjusted life-years
gross domestic product
gross national income
highly active antiretroviral therapy
healthy life expectancy
iodine deficiency disorder
multidrug-resistant TB
noncommunicable diseases
severe acute respiratory syndrome
tuberculosis
years of life lost due to premature mortality
YLD
years lived in disability
FOREWORD
Foreword: putting knowledge at the service
of a healthier future
The European health report 2005 was inspired by the idea that knowledge can be used to
improve people’s lives. Good future decisions on public health require the right people to have the
right information. With this report, we at the WHO Regional Office for Europe offer a practical
knowledge resource to health professionals and all other stakeholders in public health to use in
this task.
The report offers an up-to-date map of health in the 52 countries in the WHO European Region.
The analysis focuses particularly on the major determinants of health, particularly poverty and
social inequalities. It calls attention to the widening health gaps between the countries of the
Region and between the richer and poorer groups within countries. Today, a limited set of risk
factors causes the bulk of the burden of disease. The report describes this burden and how the
wider use of effective public health interventions can reduce it, spelling out some lessons learned
and giving examples of successful interventions.
In particular, the report highlights children’s health and the work being done – and still to be
done – to improve it. Healthy children become healthy adults. Despite the overall improvement
in child health in the Region, the incidence of many diseases and chronic conditions is rising
in various countries. The report shares evidence on both the risks to children’s health and the
opportunities of improving it.
Our main objective is to support countries to choose the best possible investments in health on
the basis of evidence and knowledge. We hope that this publication will be a step forward in
helping Member States to deal successfully with today’s public health challenges and those to
come.
Marc Danzon
WHO Regional Director for Europe
VII
VIII
T H E E U R O P E A N H E A LT H R E P O R T 2 0 0 5
Executive summary
Good health is a fundamental resource for social and economic development.
Higher levels of human development mean that people live longer and enjoy
more healthy years of life.
Highest
While the health of the 879 million people in the WHO European Region
San Marino: 73.4 years
has in general improved over time, inequalities between the 52 Member
Sweden: 73.3 years
States in the Region and between groups within countries have widened.
Switzerland: 73.2 years
In addition to the east–west gap in health, differences in health between
Lowest
socioeconomic groups have increased in many countries.
Kyrgyzstan: 55.3 years
Reducing inequality is increasingly vital. As most countries have declining
Tajikistan: 54.7 years
birth rates and growing elderly populations, it is particularly important to
Turkmenistan: 54.4 years
help children to avoid ill health and to become resilient enough to remain in
good health long into old age.
The European health report 2005 contributes to this task by summarizing the major public
health issues facing the Region, particularly its children, and describing effective policy
responses. This helps to supply the reliable, evidence-based information needed for sound
decision-making on public health.
East–west gap in healthy
life expectancy, 2002
Content and methods
The report first summarizes the facts on public health in the Region and then looks specifically
at children’s health and development. It ends with statistical tables giving some of the data
that form the basis for its conclusions, and definitions of some of the terms used. The report
is not a comprehensive review of all available information, but a synthesis of evidence and
analyses from WHO and various other sources. It presents evidence on the burden of disease
from particular conditions, the impact of particular risk factors and a selection of successful
initiatives and interventions that could improve public health across the Region.
The report presents the latest available figures on a variety of health indicators. Where
possible, the results are given for three groups of countries in the European Region; allocation to
these groups is based on mortality in children and adults, rather than geographical or political
factors. The report looks at life expectancy and the causes of mortality, and uses the measures
of healthy life expectancy (HALE) and disability-adjusted life-years (DALYs). Combining
these measures with traditional indicators, such as mortality rates and disease incidence and
prevalence, allows the report to highlight current issues and give a better picture of the situation
in the Region.
Tackling risk factors to reduce the burden of disease
The most important causes of the burden of disease in the Region are noncommunicable
diseases (NCDs – 77% of the total), external causes of injury and poisoning (14%) and
communicable diseases (9%). In 2002, NCDs caused 86% of the 9.6 million deaths and 77% of
the 150.3 million DALYs in the Region. They originate from complex interactions of genetics,
behaviour and the environment, and thus require long-term planning and treatment. In
addition, injuries are a particular problem for young people.
EXECUTIVE SUMMARY
Further, poverty and underfunded services create a double burden of noncommunicable
and communicable diseases for some countries in the eastern half of the Region. This double
burden is partly responsible for the health gaps between and within countries.
Just seven leading risk factors – tobacco, alcohol, high blood pressure, high cholesterol,
overweight, low fruit and vegetable intake and physical inactivity – are mainly responsible for
the differences between countries in the burden of disease due to seven leading conditions
– ischaemic heart disease, unipolar depressive disorders, cerebrovascular disease, alcohol use
disorders, chronic pulmonary disease, lung cancer and road-traffic injury. Using well-known
interventions to tackle the risk factors would largely prevent these conditions. This creates a
compelling argument for action.
The report highlights success stories from across the Region to illustrate how NCDs and
injuries can be attacked by concerted, yet relatively simple measures. Countries have a choice
of measures for certain diseases, and sharing information on the successes and limitations of
interventions is vital to their adaptation and use in other countries. For example, the success
of Sweden’s Vision Zero initiative in reducing traffic injuries has led to its adoption by several
other countries. The topics and home countries of the success stories vary; what they share is
their involvement of all stakeholders, from patients to health care providers to government
and other bodies. These examples prove that simple but comprehensive measures can lead to
important benefits for health.
Focus on children
The European health report 2005 has a special focus on children’s health, because health in
childhood determines health throughout life and into the next generation. The period between
birth and 5–6 years of age is critical. Ill health or harmful lifestyle choices in childhood can lead
to ill health throughout life, which creates health, financial and social burdens for countries
today and tomorrow.
Health patterns and problems in children
Overall, the health status of children in the 52 countries in the WHO European Region reflects
the widening east–west gap seen in adults. Despite overall improvement, children’s health in the
European Region shows large differences according to age, gender, geographical location and
socioeconomic position, both within and between countries. Social inequalities are increasing
in all countries, but particularly in the eastern half of the Region.
The inequalities in children’s health are unacceptably large, and overwhelmingly affect the
countries, societies, communities, families and children with the fewest resources to cope with
them. Even in more affluent countries, the poorer members of society carry a disproportionate
share of the disease burden.
The causes and rates of illness and death in children vary widely across the Region. In
particular, eastern countries have higher morbidity and mortality from respiratory and
infectious diseases, and injuries and poisoning, which create a different pattern than that of
ill health in adults. In the western countries, mortality from these causes is already very low,
which means a smaller disease burden overall. Children’s disease patterns in western countries
therefore include proportionately more NCDs, such as asthma and allergies, diabetes, obesity
and neuropsychiatric disorders. Vaccine-preventable diseases remain a worry across the Region.
Poverty is the greatest threat to children’s health, regardless of a country’s level of
development. Rates of disease and harmful behaviour are closely linked to socioeconomic
IX
X
T H E E U R O P E A N H E A LT H R E P O R T 2 0 0 5
factors, which include poor neonatal health (from malnutrition, for example), lack of access
to health care, unhealthy or unsafe environments, and behavioural factors such as poor diet,
physical inactivity and early smoking, drinking or drug taking.
The different patterns of child and adult health underline the need for countries to design
complementary health strategies for the two. Because working for optimal health and
development for all children is an increasingly complex task for countries, the WHO Regional
Office for Europe is developing a new approach to assist them: a European Strategy for Child
and Adolescent Health and Development. In addition, all countries need better information on
and monitoring systems for children’s health, particularly in relation to social inequalities.
Successful policies: applying available knowledge in comprehensive strategies
Investing in children’s health is a way of investing in the future, and brings health, financial and
social benefits. The European health report 2005 calls for renewed effort to protect and promote
children’s health. While the report points out that a responsible balance must be struck between
current burdens and future benefits for the whole population, it also makes clear that investing
in children’s health and development not only is a key to a population’s future health but also
will reduce today’s inequalities.
Much of the knowledge required to improve health for everyone in the Region is already
available; the challenge is transforming it into action.
Despite the wide differences in the health problems of children across the WHO European
Region, the evidence shows that successful health promotion and disease prevention
programmes share some common factors. The most successful interventions:
•
•
•
•
•
•
are created as part of comprehensive national planning involving all stakeholders, including
children;
are based on solid evidence on the target populations, the interventions’ effectiveness and
country health systems’ capacity for implementation;
address both the broad determinants of ill health – poverty and social inequality – and
particular risk factors;
involve multisectoral, multifaceted and multilevel action by government and other
stakeholders, using the whole array of available policy instruments and calling on wide social
support for change;
target the populations in most need; and
are adapted to local needs, resources and circumstances, including cultural, religious and
gender factors.
Focusing on children’s health now can improve adult health in the future. While more effort
and, naturally, resources are needed for the successful implementation of the interventions
known to be effective, action for children’s health and development primarily requires the
ambition to pursue substantial improvements. Much work is needed, but, as The European
health report 2005 shows, today’s effort is tomorrow’s success.
INTRODUCTION
2
T H E E U R O P E A N H E A LT H R E P O R T 2 0 0 5
Introduction
The task
Good health is a fundamental resource for social and economic development. Unquestionable
evidence shows inextricable links between health and sustainable human development. Health
is also one of the fundamental rights of every human being. That is why it is encouraging to
know that health in the WHO European Region has improved considerably over time.
Nevertheless, the Region also displays glaring contrasts. On the one hand, its richest and
most developed countries are among the healthiest on the planet in terms of longevity, late onset
of disease and disability and increased attention to the ability to function and the quality of life.
On the other hand, the Region also contains poor countries that are still struggling with severe
ill health among younger groups in their populations. These countries carry a double burden
of disease: they lack the advanced means of controlling the traditional burden of infectious
diseases and injuries, while already carrying a large modern burden of noncommunicable
diseases. Further, all countries, even the most affluent, have vast and growing inequalities in
health between the richest and poorest people. Reducing inequalities within a population to the
minimum feasible is a key challenge for every country.
The means
WHO believes that sharing information and knowledge helps equip countries to reduce
inequalities in health. As a result, The European health report 2005 first reviews and summarizes
the evidence on the state of public health in the Region and the main interventions that can
improve the health of populations. Then it takes a step forward, looking at children as the
population group whose improved health would bring the greatest cumulative effects and
identifying common factors in successful programmes to prevent disease and promote health in
this group. Action at the start of life can reap lifelong benefits; actors in the health field should
seize all opportunities to obtain them. The report ends with statistical tables giving some of the
data that form the basis for its conclusions, and definitions of some of the terms used.
This report draws extensively on evidence gathered and analyses made for the 2002 and
2004 WHO world health reports (1,2) and the WHO Global Burden of Disease project (3). It is
also founded on various databases and publications of the WHO Regional Office for Europe,
especially those related to sessions of the WHO Regional Committee for Europe (WHO’s
governing body in the Region), ministerial conferences and high-priority technical work. Each
part concludes with a list of key sources.
The evidence indicates interventions of proven effectiveness, although this knowledge is
often not optimally transformed into action. Intersectoral action and multifaceted strategies are
needed, with a focus on disadvantaged groups. The evolving broader understanding of public
health requires the health sector to win new partners to tackle this task. Health in today’s world
is the responsibility of government as a whole, along with other stakeholders, transcending
traditional sectoral boundaries. New courage is needed to employ the new approaches to
population health that are supported by mounting evidence. The European health report 2005
traces the way forward and indicates the support available to Member States in their work to
protect and improve health.
INTRODUCTION
The message
The main message is that, while the current gaps in health are important and action is needed
to protect the whole population, ill health in children and young people has particular
significance that requires a targeted response. It can affect the health experience throughout
life; in particular, by triggering harmful behaviour and health problems, it sets the stage for poor
health and disease in adult life. Children’s ill health also has a wider impact on parents, families
and society. Moreover, each period of child development poses a new set of health challenges
and requires policies tailored to it.
Special effort should therefore be made to invest in children’s health as much as necessary
in any given situation. Dramatic social and economic transformations are underway in
countries, communities, families and individuals; these add to the complexity of this challenge.
A responsible balance must be struck between current burdens on and future benefits for the
whole population, but investing in children’s health and development is not only a key to the
future health of the population but will also reduce inequalities within it. This is the rationale
that has inspired this report.
3
4
T H E E U R O P E A N H E A LT H R E P O R T 2 0 0 5
Conceptual framework of the report
Background: implications of multifactorial health
for policy-making
Many factors shape the health of populations: genetic and biological factors, individual
lifestyles, conditions in the living and working environments, and health care services.
Moreover, socioeconomic factors underlie the major determinants of health in both children
and adults. They have a profound effect on mortality, morbidity and health-related behaviour
from conception and birth, through the most important early years of development to the end
of life. This multifactorial nature of health makes it appropriate for policy-makers to take a
broad view of all the factors that may affect its determinants and outcomes.
In addition, these multiple determinants influence people’s health through a dynamic and
continuous interaction between biology, past exposures and current life circumstances. They
also interact over time, so their effects on health accumulate. People who have been more
exposed to risk factors in the past tend to respond less resiliently to current and future pressures
in life. Many chronic diseases in adults have their origins in childhood.
These circumstances have three implications for policy-making.
1. Policy-making on health requires a broad view, with a focus on the environment – in the
broadest sense – to which people are exposed.
2. Health and social policies need to work upstream, on the precursors of unhealthy behaviour,
chronic diseases and mental disorders, and to provide services and programmes along the
entire lifespan to offset earlier exposures to risk factors.
3. In general, the most appropriate public health interventions are multifactorial and
comprehensive, address diverse aspects of a health problem and consider individuals in the
context of their living, working and social circumstances.
Approach of this report
Accordingly, this report uses a broad analytical framework, focused on the different
developmental stages along the lifespan and based largely on reviewing both the disease burden
and the relevant health determinants and interventions for the population as a whole and,
more specifically, for children. The burden-of-disease approach helps the report to focus on
the big picture and to attach the highest importance to the biggest problems. Support from the
database of the WHO Global Burden of Disease project (3), tailored specifically to the needs of
this report, enabled this approach to be used. In addition, the report highlights the relevance
of factors and interventions in earlier developmental stages, which offers opportunities vital to
building healthier populations for the future.
The nature and comparability of the available data limit the scope of the analyses that can be
made. Although existing data are mainly on negative indicators, children’s health encompasses
both hazards and positive dimensions. One of the latter is the extent to which children are
able to realize their potential to achieve success in their lives. In addition, while the scientific
evidence shows the importance of the socioeconomic determinants of health, some of the
indicators were not linked to information on levels of income, education and other social
characteristics at the country level.
CONCEPTUAL FRAMEWORK
Although access to and the provision of appropriate, high-quality health care services are vital
and a basic human right, the report focuses mainly on health determinants and uses examples of
effective service interventions where necessary. This is in accordance with the WHO policy for
health for all, which suggests that countries pull together the contributions of all direct and indirect
factors that influence health, and allocate resources to address each of these factors in relationship to
their relative weight and demonstrated impact.
Methods
Using this conceptual framework, The European health report 2005 addresses the broad public
health issues in the WHO European Region, presenting the evidence on:
•
•
•
•
•
the burden of disease from specified conditions;
the strength of the impact of specific risk factors on diseases and conditions; and
selected public health interventions that can clearly improve the health situation, provided that
the contextual factors for successful implementation are taken into account.
The burden of disease is expressed using both:
conventional indicators, such as mortality, incidence and prevalence; use of resources of the
health care and social systems; and cost to the economy; and
summary measures of levels of and gaps in population health, such as healthy life expectancy
(HALE) and disability-adjusted life-years (DALYs).
Although the importance of socioeconomic determinants of health should always be kept in
mind, the quantitative estimates of impact are in general limited to the effects of direct determinants
and are derived by statistical techniques that artificially separate the effect of one risk factor from
those of other factors. Nevertheless, the reader should remember that such factors often operate
simultaneously and interact.
The examples of interventions given were selected on the basis of systematic reviews of evidence,
but the report also highlights widely accepted good practices and illustrates them with success
stories.
At this point, it is necessary to emphasize the need for caution in using the indicators and other
evidence in the report. The conventional indicators and the summary measures are mutually
supportive, rather than alternatives. The former can provide timely and very specific information
on the health situation and trends and the responses of health systems, while the latter amalgamate
information on the basis of various assumptions and generalized statistical models. Summary
measures are intended to standardize information from very different sources, while single
indicators aim to reveal points for targeted action. There is a trade-off between specificity and crosscountry comparability here. Both precise but very numerous individual indicators and standardized
summary measures (which can provide an overview of the total burden and express this in common
measures) are therefore useful. In the complex process of tracing changes in health patterns, both
have their uses and strengths. In addition, summary estimates may be the most robust or sensitive
measures in areas where the regular reporting systems do not provide solid conventional indicators.
The Global Burden of Disease project has produced country-specific DALY estimates for all
countries in the WHO European Region, by condition and known risk factors. WHO’s methods
were developed to maximize comparability across populations. The analyses take account of
incomplete coverage of cause-of-death registration in countries and are adjusted for biases in selfreported morbidity data from surveys. In addition, steps are being taken to incorporate adjustments
in the statistical data modelling for dependent comorbidity and populations in institutions, which
5
6
T H E E U R O P E A N H E A LT H R E P O R T 2 0 0 5
are usually difficult to estimate and account for statistically. Nevertheless, the DALY and HALE
estimates should be considered in the context of the explicit uncertainties, which are part
of the estimates, and used carefully. The WHO estimates presented may therefore be better
understood as the best available approximations, rather than results of direct measurement.
In essence, the identifiable risk factors usually contribute to the causation of several
conditions, so the total actual impact of a factor may be greater than its estimated effect on a
specific condition. At the same time, because the effects of the individual risk factors are not
independent but interrelated, the total effect of a group of factors contributing to a condition
is usually not equivalent to the sum of the DALYs attributable to each of them. Determining
the total effect requires additional statistical adjustments to be made. On the other hand, one
person may acquire several diseases, each of which is related to the same risk factors; this also
needs to be taken into account. Putting all of these scenarios together, summary measures
can provide additional insights that cannot be gained from solely using specific conventional
indicators.
Lessons and considerations for policy are derived from the work of the WHO Regional
Office for Europe, internal reviews and consensus estimates. Evidence of interventions’
demonstrated impact has been systematically sought, but not necessarily graded. These
searches have been deliberately limited to priority areas, as defined by the magnitude of the
disease burden and the attributable risk.
Country groupings
In attempting to facilitate analysis, compare and identify trends and priorities, it is useful to
group countries. Various approaches can be used.
For The European health report 2002 (4), the criterion used to group countries was the
traditional distinction between such entities as the European Union (EU), the countries of
central and eastern Europe and the newly independent states of the former USSR. The latter
TECHNICAL NOTE
Epidemiological subregions of the WHO European Region
To aid analyses of mortality and the burden of disease,
WHO (1) introduced the division of WHO Member States
into five mortality strata on the basis of their levels of
mortality in children under 5 years of age and male adults
aged 15–59 years. Quintiles of the distribution of child
mortality (both sexes combined) were used to define
groups in which mortality was very low (1st quintile), low
(2nd and 3rd quintiles) and high (4th and 5th quintiles).
The groups with low and high child mortality were
further qualified by the level of adult mortality (using
the regression line of adult mortality on child mortality).
In this way, five global mortality strata were defined:
• A: very low child and adult mortality
• B: low child and adult mortality
• C: very low child and high adult mortality
• D: high child and adult mortality
• E: high child and very high adult mortality
The Member States in the 6 WHO regions in
the world were allocated to 14 epidemiological
subregions. The WHO European Region was divided
into three such subregions, called Eur-A, -B and -C:
1. Eur-A (27 countries with very low mortality in both
children and adults): Andorra, Austria, Belgium,
Croatia, Cyprus, the Czech Republic, Denmark, Finland,
France, Germany, Greece, Iceland, Ireland, Israel,
Italy, Luxembourg, Malta, Monaco, the Netherlands,
Norway, Portugal, San Marino, Slovenia, Spain,
Sweden, Switzerland and the United Kingdom;
2. Eur-B (16 countries with low mortality in both children
and adults): Albania, Armenia, Azerbaijan, Bosnia
and Herzegovina, Bulgaria, Georgia, Kyrgyzstan,
Poland, Romania, Serbia and Montenegro, Slovakia,
Tajikistan, The former Yugoslav Republic of Macedonia,
Turkey, Turkmenistan and Uzbekistan; and
3. Eur-C (9 countries with low child mortality and
high adult mortality): Belarus, Estonia, Hungary,
Kazakhstan, Latvia, Lithuania, the Republic of
Moldova, the Russian Federation, Ukraine.
These mortality strata were defined on the basis
of empirical information and statistically modelled
death rate estimates. WHO used this classification
in its world health reports through 2004 (2).
CONCEPTUAL FRAMEWORK
7
Fig. 1.
Epidemiological
subregions of
WHO European
Region: Eur-A,
Eur-B and Eur-C
Eur-A
Eur-B
Eur-C
were defined as the 15 countries that became independent after the dissolution of the USSR,
including Estonia, Latvia and Lithuania. The countries of central and eastern Europe comprised
12 countries of the formerly centrally planned economies of central and eastern Europe that
were not part of the USSR. When the grouping western Europe was used, it included the
15 members of the EU and the developed market economies outside it. This approach was
considered to be losing relevance at that time, and is less appropriate now, after 10 countries
(Cyprus, the Czech Republic, Estonia, Hungary, Latvia, Lithuania, Malta, Poland, Slovakia and
Slovenia) entered the EU in May 2004.
As well as using some general geographical groupings, The European health report 2005
therefore allocates countries into three groups – Eur-A, Eur-B and Eur-C – according to levels
of mortality (Fig. 1), to gain a more useful picture of health in the Region (see technical note and
The world health report 2004 (2)). This approach was first established by WHO headquarters
and is based on data from countries and statistically modelled estimates from WHO.
8
T H E E U R O P E A N H E A LT H R E P O R T 2 0 0 5
The use of this approach, it is hoped, will enrich the traditional approach of grouping
the countries in the European Region by geographical location and/or affiliation to some
international structure. Although the geopolitical approach is useful for some purposes, it
should be balanced by another distribution of countries, using some neutral concept. This
should assist judgement of the actual health situation.
References
1. The world health report 2002 – Reducing risks, promoting healthy life. Geneva, World Health
Organization, 2002 (http://www.who.int/whr/2002/en/, accessed 27 April 2005).
2. The world health report 2004 – Changing history. Geneva, World Health Organization, 2004
(http://www.who.int/whr/2004/en, accessed 27 April 2005).
3. Mathers C et al. Global burden of disease in 2002: data sources, methods and results. Geneva,
World Health Organization, 2004 (http://www3.who.int/whosis/menu.cfm?path=evidence,
burden,burden_gbd2000docs,burden_gbd2000docs_DP54&language=english, accessed 27
April 2005).
4. The European health report 2002. Copenhagen, WHO Regional Office for Europe, 2002
(http://www.euro.who.int/europeanhealthreport, accessed 27 April 2005).
THE
GENERAL
PUBLIC HEALTH
PERSPECTIVE
10
T H E E U R O P E A N H E A LT H R E P O R T 2 0 0 5
Overview
This part of the report maps the health gaps in the
While the WHO European Region
Region as measured by DALYs. These are statistical
continues moving towards low
estimates of currently unrealized years of healthy
levels of fertility and premature
life on average for a given country population and
mortality, differences between and
as compared to a reasonably feasible standard (see
within countries have widened.
technical note below).
In addition to the east–west gap
in life expectancy, socioeconomic
DALYs serve two purposes: they can be used to
gradients in mortality have
estimate the current burden created by causes of ill
increased in many countries.
health such as disease and injuries, and they can be
Fortunately, well-known and
attributed to preventable risk factors, or causes in an
feasible public health interventions
etiological sense, to estimate the avoidable burden
can greatly reduce the years of
in the future. These summary indicators of health
life lost to illness and premature
gaps ensure that all diagnosable health outcomes
death. Interventions addressing
(both deaths and non-fatal outcomes) are assigned
the seven leading risk factors
to a defined category and contained in one account
can largely prevent the leading
of the total disease burden that a population has to
seven conditions. This creates a
carry. The total burden can then be sorted by the
compelling argument for action to
reduce these risks to the minimum
size of its constituent parts; these can be further
possible.
assessed to determine whether and to what extent
they can be avoided through reducing behavioural
and environmental hazards.
On this basis, the leading causes and risk factors can be identified and used as a canvas on
which to picture the relevant evidence on the health situation: achievements, problems, policy
considerations and interventions. Such a DALY-based canvas lends a simple but solid logic to
the report because it leaves no doubt about the real proportions of the constituent health gap,
as the lists of categories used are complete and do not overlap. This helps the reader to keep
sight of the big picture and avoid bias in epidemiological judgement.
In addition to DALYs, as one summary measure of health, the core of the report rests on
two other such measures: life expectancy and its mortality correlates, and HALE, an indicator
of the quality of the current average lifespan. This combination of summary measures
of health levels and health gaps makes up the firm structure needed to assess the general
situation of public health in the Region today.
Population of the WHO European Region
The total population of the 52 countries in the WHO European Region was estimated at
879.6 million in 2003 (see also Annex Table 1). (The population data in this section come
mainly from WHO (1), the United Nations Development Programme (2) and the Council of
Europe.) In general, countries continue moving towards low levels of fertility and premature
mortality. Natural population growth (the excess of births over deaths) is declining and is
negative or only marginally positive in many countries, particularly those in the eastern half
of the Region, in many of which the decline started in or even before 1990.
OVERVIEW
Family structures show major changes. The trends point to a declining number of marriages
and an increase in separations and cohabitation, with a parallel increase in the number of births
outside marriage. The declining marriage rate is accompanied by an increase in the age at first
marriage. Changes in the structure of families can affect parents’ relationships with children
and consequently children’s well-being and development. Continuing to track and understand
the effect of these changes is essential to providing children with a good start in life. This could
include looking at broader policies and laws that affect families, such as those on marriage,
divorce and custody arrangements.
The fertility rate in the Region – the average number of children expected to be born per
woman during her reproductive years – is in general below the replacement level of 2.1, except
in the central Asian republics, Israel and Turkey. In addition, women show a growing tendency
to delay their first pregnancies. This increases the risk of congenital anomalies and leads to a
decrease in families with three or more children. First and second births comprise a higher
proportion of the total.
In recent decades, mortality has declined substantially in most countries in the Region. In
Eur-A, people now live longer, as mortality here is considerably lower than in most countries in
Eur-B and -C.
The combination of declining fertility and mortality has raised the proportion of older
people (aged 65 years and over) in the population. Practically all Member States have ageing
populations. This demographic transition is expected to continue, and the share of older
people in the total population will continue to grow. As fewer children are born and people live
longer, greater care than ever must be taken to help children not only to avoid sickness but to be
maximally resilient to the stresses of life and capable of maintaining good health into very old
age.
Longevity and mortality
Life expectancy has risen across the Region since 1990, with women in general living longer than
men, but increased differences between countries and worrying increases in early death in men
in eastern countries, particularly middle-aged men in Eur-C, need to be addressed.
Life expectancy
Average life expectancy is the standard summary measure of the length of the lifespan. The
average for the Region has reached 74 years, an increase of 1 year since 1990. The life-expectancy
estimates in this section are based exclusively on official statistics of Member States and may
differ from those in Annex Table 2, which were computed by WHO to assure comparability.
Life expectancy has recouped the losses of the mid-1990s, although several countries in the
Commonwealth of Independent States (CIS) still struggle to regain the positions they held in
1990. Differences between individual countries, and between Eur-A, -B and -C, however, have
widened (Table 1).
Countries such as the Czech Republic, Hungary and Poland have made big strides, but others
were in turmoil in the early 1990s, with significant declines in life expectancy. The difference
between the countries with the highest and lowest estimated average life expectancy rose from
about 12 years in 1990 (Iceland and Sweden versus Turkey and Turkmenistan) to about 15 years
in 2003 (Iceland and Switzerland versus Kazakhstan and the Russian Federation).
In many countries, the average life expectancy for women is now over 80 years, particularly in
Eur-A (Fig. 2). Eur-C males have the lowest figures. The average gap in life expectancy between
11
12
Table 1. Life
expectancy at
birth in the WHO
European Region
T H E E U R O P E A N H E A LT H R E P O R T 2 0 0 5
Life expectancy (years)
Country
1990
1995
Latest
available
(year)
Albania
Andorra
Armenia
Austria
Azerbaijan
Belarus
Belgium
Bosnia and Herzegovina
Bulgaria
Croatia
Cyprus
Czech Republic
Denmark
Estonia
Finland
France
Georgia
Germany
Greece
Hungary
Iceland
Ireland
Israel
Italy
Kazakhstan
Kyrgyzstan
Latvia
Lithuania
Luxembourg
Malta
Monaco
Netherlands
Norway
Poland
Portugal
Republic of Moldova
Romania
Russian Federation
San Marino
Serbia and Montenegro
Slovakia
Slovenia
Spain
Sweden
Switzerland
Tajikistan
TFYR Macedoniab
Turkey
Turkmenistan
Ukraine
United Kingdom
Uzbekistan
European Region
Eur-A
Eur-B
Eur-C
72.6
NAa
72.1
76.0
71.4
71.3
76.3
72.9
71.5
72.6
NA
71.5
75.1
69.9
75.1
77.6
73.0
75.5
77.2
69.5
78.2
74.8
76.8
77.2
68.8
68.8
69.5
71.6
75.5
76.2
NA
77.2
76.7
71.0
74.1
68.6
69.8
69.3
NA
NA
71.1
74.1
77.0
77.8
77.6
70.0
NA
66.2
66.6
70.5
75.9
69.7
73.1
76.3
69.5
69.6
74.9
NA
73.0
77.1
69.5
68.6
77.1
NA
71.0
73.3
NA
73.3
75.5
67.8
76.8
78.7
70.4
76.8
77.8
70.1
78.0
75.5
77.5
78.4
64.7
65.5
66.3
69.2
77.4
77.3
NA
77.7
77.9
72.0
75.3
65.9
69.4
64.7
79.9
72.7
72.5
74.9
78.1
79.1
78.8
68.0
72.2
68.0
65.2
66.9
76.8
67.9
72.5
77.4
69.7
65.6
75.8 (2003)
NA
73.1 (2003)
78.9 (2003)
72.4 (2002)
68.5 (2003)
77.6 (1997)
72.7 (1991)
72.4 (2003)
74.7 (2003)
79.4 (2003)
75.4 (2003)
77.2 (2000)
71.2 (2002)
78.7 (2003)
79.4 (2000)
76.1 (2001)
78.8 (2001)
79.0 (2001)
72.6 (2003)
80.9 (2001)
77.2 (2001)
79.7 (2003)
80.3 (2001)
65.9 (2003)
67.9 (2003)
71.0 (2003)
72.2 (2003)
78.9 (2003)
78.6 (2003)
NA
78.8 (2003)
79.1 (2002)
74.7 (2002)
77.3 (2002)
68.1 (2003)
71.0 (2002)
64.9 (2003)
82.3 (2000)
72.7 (2002)
73.9 (2002)
76.5 (2003)
79.8 (2001)
80.0 (2001)
80.5 (2001)
72.0 (2001)
73.5 (2003)
70.0 (2003)
66.1 (1998)
67.8 (2003)
78.5 (2002)
70.0 (2002)
74.0
79.0 (2003)
71.6 (2002)
66.3 (2003)
a
NA= not available.
The former Yugoslav Republic of Macedonia
Source: European health for all database (3).
b
women and men in the Region is about
8 years: about 4 years in Tajikistan and
Iceland, but 13 years in the Russian
Federation. In general, the female–male
differences in life expectancy between
countries decreased in the 1990s. These
differences are smallest in Eur-A, where
the difference decreased considerably,
while life expectancy in Eur-B increased
more for men than women. The
difference grew in Eur-C, however,
where male mortality increased in
several CIS countries.
Mortality and socioeconomic
factors
The mortality crises in several CIS
countries have been accompanied by
increasing inequality in socioeconomic
indicators, at least temporarily
(Annex Table 3). In the early 1990s,
the Russian Federation and Ukraine
were among those with the largest
increases in income inequality (4) and
in mortality among middle-aged men,
although the most recent surveys show
improvements. Among the countries in
the eastern half of the Region, relatively
small increases in income inequalities
were found in the Czech Republic,
Hungary and Poland, where male life
expectancy at birth rose.
Gradients in mortality between
socioeconomic groups have increased
in many western European countries,
too, such as France, the Nordic
countries and the United Kingdom (5).
Underlying societal changes have
shaped the health trajectories of
populations in the European Region,
across countries and socioeconomic
subgroups. In many cases, unfavourable
mortality trends in particular
socioeconomic subgroups are
probably behind the increasing health
inequalities in countries. In general,
OVERVIEW
Fig. 2. Life expectancy at
birth by sex and country
grouping, 1980–2003
85
Eur-A, females
80
Eur-A, males
Life expectancy (years)
75
Eur-B, females
Eur-C, females
70
Eur-B, males
65
Eur-C, males
60
55
1980
1985
1990
1995
Year
2000
2005
Source: European health
for all database (3).
disadvantaged groups benefit later from improvements in health determinants. They are also the
most vulnerable when unexpected societal changes occur. Evidence is accumulating, however,
that such vulnerability is related to negative changes in people’s relative position in society, which
create long periods of unhealthy psychosocial stress. This can result in unhealthy behaviour,
particularly in the absence of supportive social environments and personal coping skills (6–9).
Amenable mortality
Analysis of amenable mortality – the deaths that would be preventable if all the relevant medical
knowledge, services and resources of the health system and society were optimally applied – can
address the question of how much health systems specifically contribute to health. The results
could indicate the levels of utilization of the available knowledge in practice. The question has two
parts: what are the contributions of health care and of public health programmes to population
health outcomes?
This report addresses the latter, as amenable mortality can show the impact of primary and
secondary prevention. Primary prevention – interventions to reduce people’s exposure to
lifestyle and occupational risk factors for diseases and injuries – should reduce the incidence
and deadliness of amenable conditions. Secondary prevention comprises screening, early case
detection, diagnosis and adequate treatment.
13
14
T H E E U R O P E A N H E A LT H R E P O R T 2 0 0 5
Table 2 shows a time cross-section of such conditions (10) and the mortality rates in the
countries in the Region. Countries show little difference in some conditions, such as melanoma
of the skin and breast cancer, but large differences, which mean potential for improvement, in
others, such as stroke, liver diseases, cancer of the uterus and traffic accidents.
Over time, amenable mortality is one of the factors underlying the differentials in mortality
between countries. A recent study showed that, in 1980–1997, amenable mortality declined in
all the countries that comprised the EU before May 2004 (11). The largest variations in trends
between countries, however, appeared in conditions mainly subject to prevention strategies.
Several countries showed trends that deviated significantly from the average, and some large
avoidable causes had relatively unfavourable trends.
Similarly, amenable mortality can explain a large part of the east–west gap in life expectancy.
Andreev et al. (12) compared trends in life expectancy in the Russian Federation and the United
Kingdom and their components attributable to amenable mortality. In the period 1965–1999,
mortality from such causes remained practically unchanged in the Russian Federation (apart
from fluctuations), while the rates in the United Kingdom steadily declined. In 1999, amenable
causes were responsible for differentials in life expectancy between the two countries: three
years in men and two years in women.
Differences across countries and population groups indicate how much impact policies to
prevent and control major risk factors – such as high blood pressure, high cholesterol, smoking,
etc. – could have. They also show that no country consistently has the best results on all indicators.
Rather, every country can learn from comparisons with its peers and benefit from their knowledge,
if appropriately transferred and adapted for use according to local needs and resources.
Healthy time lived and healthy time lost
Rising life expectancy makes it more important for public health professionals to have
information on non-fatal health problems and rates of good health. HALE (healthy life
expectancy) and DALYs (disability-adjusted life-years) allow this analysis, and reveal that
higher levels of health development mean more healthy years of life and that noncommunicable
diseases present the Region with its biggest challenge.
Summary measures of population health combine information on population mortality and
non-fatal health outcomes, to represent a population’s state of health in a single number (see
technical note).
HALE
The methodology of HALE estimations has improved considerably in recent years. This has
created momentum in countries: HALE is increasingly calculated at country and subnational
level and, no less important, public health experts and authorities have started to demand HALE
estimates to assist their policy-making. They appreciate that HALE can usefully complement
traditional health indicators. For example, an analysis of HALE in the Russian Federation (13)
provided insights into patterns of population health in different age groups and by sex; these
differ from the mortality patterns. Public health experts in the United Kingdom (14) recognize
that HALE provides valuable information on morbidity and health care use and can therefore
complement the analyses of population health needs and health inequalities that form the
basis for the allocation of resources at the subnational level (15). HALE is a practical summary
measure of population health, because the indicator is easy to communicate and suitable data
are available in many countries of the Region through registers and population surveys.
OVERVIEW
15
Table 2. Mortality amenable to primary or secondary prevention: average deaths per 100 000 population
Country
Albania
Andorra
Armenia
Austria
Azerbaijan
Belarus
Belgium
Bosnia and Herzegovina
Bulgaria
Croatia
Cyprus
Czech Republic
Denmark
Estonia
Finland
France
Georgia
Germany
Greece
Hungary
Iceland
Ireland
Israel
Italy
Kazakhstan
Kyrgyzstan
Latvia
Lithuania
Luxembourg
Malta
Monaco
Netherlands
Norway
Poland
Portugal
Republic of Moldova
Romania
Russian Federation
San Marino
Serbia and Montenegro
Slovakia
Slovenia
Spain
Sweden
Switzerland
Tajikistan
TFYR Macedoniac
Turkey
Turkmenistan
Ukraine
United Kingdom
Uzbekistan
a
b
c
Mortality amenable to primary prevention
Motorvehicle
traffic
injurya
Cerebrovascular
disease
Chronic
liver
disease
and
cirrhosis
6.0
NAb
5.7
10.2
5.7
16.2
15.2
NA
10.0
13.9
NA
11.2
9.1
16.8
7.5
12.6
4.8
8.8
19.1
13.1
8.4
10.4
9.6
12.0
11.4
11.5
25.3
21.7
14.8
4.0
NA
6.6
7.2
18.4
16.1
13.4
12.5
20.6
14.8
8.4
13.5
14.1
13.9
5.5
6.7
7.3
6.8
NA
9.5
12.5
5.7
8.7
20.9
NA
26.0
9.2
33.9
58.3
9.1
30.5
45.7
27.0
NA
16.3
10.9
35.3
11.6
7.1
49.5
8.3
12.6
33.7
6.2
9.7
8.2
7.7
68.4
88.6
43.3
24.7
11.4
7.3
NA
8.4
7.1
23.1
18.4
67.0
51.1
68.6
4.0
39.3
16.8
15.1
8.0
7.7
4.7
32.1
38.7
NA
39.9
52.7
10.7
47.0
0.0
NA
7.7
13.8
22.3
11.0
8.2
12.1
12.0
21.2
NA
13.5
12.7
16.9
10.3
11.1
14.4
13.6
2.5
53.6
1.4
3.6
2.7
7.4
21.8
34.7
11.5
15.7
12.6
3.3
NA
3.4
3.9
9.3
12.3
62.8
35.1
NA
3.5
6.6
22.4
24.0
7.5
3.4
5.8
19.4
5.4
NA
28.2
21.9
6.7
30.7
Average deaths per 100 000 population, all ages.
NA = not available.
The former Yugoslav Republic of Macedonia
Source: European health for all database (3).
liver
4.7
NA
NA
2.5
NA
NA
1.6
NA
4.3
3.0
NA
3.4
1.6
2.4
1.6
3.5
NA
1.7
3.1
3.3
1.1
1.2
1.2
4.2
NA
NA
2.1
1.8
1.7
1.1
NA
1.0
0.6
2.9
2.0
5.0
4.3
NA
0.0
3.5
3.2
2.3
2.8
1.5
2.1
NA
3.6
NA
NA
NA
0.8
NA
Mortality amenable to secondary prevention
Cancer of the:
lung
upper
airway and
digestive
tract
1.3
NA
2.1
5.6
4.5
7.1
6.2
3.4
4.1
8.1
NA
6.4
5.4
6.9
2.5
9.6
2.2
6.3
1.6
18.4
2.1
5.0
1.4
3.6
9.7
4.9
6.1
8.6
7.7
2.9
NA
4.7
2.7
5.7
6.3
7.7
7.0
7.1
1.7
4.4
13.5
7.5
5.9
2.3
5.0
5.9
2.4
0.0
13.8
7.7
5.0
6.7
13.3
NA
19.3
17.8
12.6
25.5
25.6
27.4
22.8
28.4
NA
27.1
23.7
22.6
10.7
22.0
12.7
17.8
19.7
44.9
18.1
14.8
11.2
17.1
24.7
11.2
23.6
22.3
18.7
13.5
NA
20.6
15.2
34.3
13.9
20.9
26.7
25.9
14.5
26.6
25.1
22.7
20.0
11.0
15.1
5.3
22.8
NA
10.3
24.0
17.2
7.4
Melanoma
of the skin
breast
Cancer of the:
cervix
uteri
other
parts
of the
uterus
0.4
NA
0.7
1.5
0.4
1.5
NA
NA
0.7
2.0
NA
1.6
NA
1.7
1.2
1.1
0.5
1.1
0.6
1.6
0.7
1.1
1.5
1.2
1.3
0.7
1.4
1.5
1.5
0.8
NA
1.8
2.5
NA
0.7
1.0
0.9
NA
0.0
1.3
1.8
2.0
0.9
1.7
1.5
0.5
1.7
NA
0.8
1.8
1.4
0.4
7.4
NA
20.4
15.3
11.2
15.2
22.6
11.3
14.2
16.5
NA
14.9
23.5
19.5
14.4
17.4
16.4
17.3
13.0
19.5
12.3
22.2
20.0
15.8
15.8
9.9
17.5
17.7
15.4
20.5
NA
21.7
15.2
15.4
14.9
18.0
15.7
17.5
6.0
19.2
15.5
17.2
13.8
14.4
15.8
4.8
17.8
NA
7.9
19.1
20.6
8.5
1.0
NA
4.5
2.0
2.0
4.4
2.2
2.8
6.1
2.5
NA
4.6
3.5
5.8
1.1
1.5
4.0
2.5
1.2
6.0
2.4
3.3
1.6
0.7
5.9
6.4
5.1
9.1
2.2
1.5
NA
1.7
3.0
7.5
2.9
7.4
12.2
5.0
1.7
6.3
5.4
3.3
1.8
1.7
1.2
2.7
3.8
NA
3.4
6.0
2.7
3.9
3.3
NA
4.3
2.2
3.9
3.4
1.8
3.8
4.3
2.7
NA
3.0
1.8
2.6
1.2
2.1
5.1
1.3
1.6
2.6
1.7
1.0
1.7
2.4
4.0
2.6
3.8
2.9
1.9
2.0
NA
1.3
1.3
2.8
2.3
3.7
3.1
3.6
0.0
3.2
3.0
2.1
1.6
1.4
1.1
2.4
5.2
NA
1.8
4.0
1.2
2.3
T H E E U R O P E A N H E A LT H R E P O R T 2 0 0 5
Summary measures of population health
100
80
Survivors (%)
Two kinds of summary
measures exist, focusing
on health expectancies or
health gaps (16). The first kind
includes, for example, HALE,
which can be seen as the
health credit or the number
of healthy years people can
expect to live under current
conditions. Measures of
health gaps estimate the loss
of healthy time to premature
death and ill health, for
example, in numbers of
DALYs: the equivalent of the
healthy years that did not
happen, or the health debit.
TECHNICAL NOTE
16
60
A
C
B
40
20
0
1
10
20
30
In the figure:
Area A = time lived in full health
Area B = time lived in less than full health, weighted for severity
Area C = time lost to premature mortality
Life expectancy = A + B
Health expectancies (such as HALE) = A + f (B)
Health gaps (such as DALY) = C + g (B)
The summary measures aim to combine
information on mortality and various states
of imperfect health in a common currency of
health. In principle, these states are innumerable
and can include any deviation from complete
health, functional limitations, etc. Assessments
of these states include comparisons with a
certain ideal, norm or target, so the measures
are relative. They also include value judgements
and choices among alternatives. Summary
measures can be used, for example:
• to compare the health of two populations
• to monitor changes in the health of a given
population
• to inform public health policy on priorities
for action
• to analyse the benefits of public health
interventions.
A central quality of summary measures is the
use of a time dimension. Health expectancies
summarize the times spent at different levels of
health. (Traditional life expectancy summarizes
solely the time lived between birth and death
into a summary measure of the average time
lived.) These times naturally add up to overall
life expectancy, but a breakdown of HALE
40
50
60
Age (years)
70
80
90
100
where f is a function assigning weights to
health states in units of years on a scale
where 1 is equivalent to 1 year of full
health and g is the corresponding
inverse function on a scale where 1 is
equivalent to 1 year of full health lost
because of disease, injury or death.
into times attributable to specific diseases
or risk factors is not available at present.
The gap measures summarize the losses
of healthy time relative to a preferred norm
and involve valuation of health states and the
use of other values, such as age and equity
weighting. The losses can be attributed to
specific diseases or health determinants.
WHO uses summary measures of population
health to serve its Member States by:
• reporting on levels of and inequalities in health;
• reporting on the causes of health loss such
as diseases, injuries and risk factors;
• advising on potential gains in health
through cost-effective interventions; and
• analysing the efficiency of health systems.
Summary measures of population health have
become increasingly useful as Member States invest
increasing amounts of money in tackling public
health problems. These measures are an important
but still incomplete development in population
health studies. WHO has produced fundamental
reference material for experts in all public health
disciplines, on the construction and use of
summary measures of population health (17,18).
HALE can be used to answer two strategically important questions. Has an increase in health
accompanied the increase in longevity? What is the average time that people live in good health,
and what is the percentage of time spent in less-than-good health?
OVERVIEW
The answers are that the general increase in life expectancy has also meant a general increase
in healthy years of life, and the proportion of life spent in less-than-perfect health has decreased.
This is a major improvement of the health situation. Nevertheless, the health differentials
between populations are wider in terms of HALE than in life expectancy estimates only. As
social factors are at the root of many of these differentials, the impact of the social determinants
of health needs continuing monitoring that takes account of both mortality and non-fatal
health outcomes. This is a prerequisite for timely evaluations and reforms of health systems and
policies, which should help people to stay healthy into older age.
In 2002, HALE at birth in the Region ranged from 73.4 years in San Marino to 54.4 in
Turkmenistan (Table 3). For males, the range was from 72.1 in Iceland to 51.6 in Turkmenistan
and, for females, from 75.9 in San Marino to 56.4 in Tajikistan.
The percentage of life lived in less-than-good health varied between 9.3% (Germany) and
15.3% (Kyrgyzstan) for females, and between 7.8% (Norway) and 13.5% (Kyrgyzstan) for males.
Countries with higher life expectancy, educational levels and expenditure on public health (as
percentages of both gross domestic product (GDP) and total government expenditure) (Annex
Table 2) lost fewer healthy years of life in both absolute and relative terms.
DALYs
In 2002, the population of the WHO European Region lost an estimated total of 150.3 million
DALYs to three main groups of causes:
•
•
•
noncommunicable diseases (NCDs – 77% of the total)
external causes of injury and poisoning (14%)
communicable diseases (9%).
The bulk of the total burden is therefore due to chronic, degenerative diseases. These
comprise a very large and diverse group, but still share some common characteristics. Injuries
and communicable diseases are responsible for much smaller shares of the disease burden.
The 10 leading conditions are usually selected from among these groups, as they constitute
a manageable number of priorities and a big and reasonably representative fraction of the total
burden. The 10 leading conditions for the Region as a whole are responsible for 40.7% of total
DALYs: they are 9 NCDs and road traffic injury.
Fortunately, seven of the leading causes of DALYs are largely preventable, as their main
risk factors are behavioural, and can be influenced by the effective use of well-known and
feasible public health interventions. These seven conditions (Table 4) cause 33.8% of the total
DALYs in the Region. The other three are hearing loss (adult onset), self-inflicted injuries
and osteoarthritis; these have multiple and less well-understood risk factors, so they are more
difficult to prevent at present. The seven leading conditions result from exposure to multiple
risk factors, known and unknown.
The seven leading risk factors (Table 5) account for over half of the attributable DALYs
in the Region. Moreover, each risk factor is associated with two or more of the seven leading
conditions and, conversely, each of the conditions is associated with two or more risk factors
(see Table 6), although the links are not fully explored.
These relationships offer important opportunities to improve populations’ health. Policies
and interventions tackling the risk factors promote several positive health outcomes in the
population, because of the multicausality of many conditions, likely synergistic effects and
general societal changes, as indicated below.
17
18
Table 3. HALE at
birth in the WHO
European Region,
2002
T H E E U R O P E A N H E A LT H R E P O R T 2 0 0 5
Country
Females (years)
Estimate
Albania
Andorra
Armenia
Austria
Azerbaijan
Belarus
Belgium
Bosnia and Herzegovina
Bulgaria
Croatia
Cyprus
Czech Republic
Denmark
Estonia
Finland
France
Georgia
Germany
Greece
Hungary
Iceland
Ireland
Israel
Italy
Kazakhstan
Kyrgyzstan
Latvia
Lithuania
Luxembourg
Malta
Monaco
Netherlands
Norway
Poland
Portugal
Republic of Moldova
Romania
Russian Federation
San Marino
Serbia and Montenegro
Slovakia
Slovenia
Spain
Sweden
Switzerland
Tajikistan
TFYR Macedoniaa
Turkey
Turkmenistan
Ukraine
United Kingdom
Uzbekistan
63.3
74.6
62.6
73.5
58.7
64.9
73.3
66.4
66.8
69.3
68.5
70.9
71.1
69.0
73.5
74.7
66.6
74.0
72.9
68.2
73.6
71.5
72.3
74.7
59.3
58.4
67.5
67.7
73.7
72.3
75.2
72.6
73.6
68.5
71.7
62.4
65.2
64.3
75.9
64.9
69.4
72.3
75.3
74.8
75.3
56.4
65.0
62.8
57.2
63.6
72.1
60.9
Males (years)
Uncertainty
limits
61.7
73.7
61.1
72.9
57.0
63.6
72.8
64.7
66.0
68.4
67.1
70.2
70.6
67.5
72.7
74.0
64.8
73.4
72.3
67.6
72.7
70.8
71.6
74.0
58.0
56.9
66.7
67.0
73.1
71.4
74.4
72.0
72.8
67.9
71.1
61.2
64.3
63.6
75.0
63.7
68.7
71.6
74.6
74.0
74.5
54.5
63.7
61.7
55.9
62.8
71.3
59.4
63.9
75.5
63.1
74.3
59.4
65.5
74.1
67.2
67.7
70.0
70.0
71.7
71.8
70.5
74.1
75.4
67.7
74.8
73.8
69.0
74.2
72.3
73.1
75.5
60.0
59.1
68.5
68.6
74.7
73.4
76.0
73.4
74.4
69.2
72.5
62.9
66.3
65.4
78.0
65.3
70.2
73.1
76.1
75.5
76.0
57.6
65.6
64.0
57.8
64.7
73.0
61.4
Estimate
59.5
69.8
59.4
69.3
55.8
56.6
68.9
62.3
62.5
63.8
66.7
65.9
68.6
59.2
68.7
69.3
62.2
69.6
69.1
61.5
72.1
68.1
70.5
70.7
52.6
52.2
58.0
58.9
69.3
69.7
70.7
69.7
70.4
63.1
66.7
57.2
61.0
52.8
70.9
62.7
63.0
66.6
69.9
71.9
71.1
53.1
61.9
61.2
51.6
54.9
69.1
57.9
Uncertainty
limits
58.0
68.5
58.3
68.6
54.5
55.7
68.3
60.8
61.6
63.2
65.9
65.2
68.0
58.6
68.0
68.6
61.1
68.9
68.4
60.9
71.2
67.3
69.4
70.0
51.6
51.2
57.2
58.1
68.6
68.9
70.0
69.1
69.5
62.4
66.0
56.2
59.9
51.9
69.4
62.0
62.3
65.8
69.1
71.2
70.3
51.7
61.0
60.3
50.8
54.1
68.5
56.9
60.8
70.7
60.5
70.0
57.2
57.5
69.5
63.9
63.3
64.6
67.5
66.5
69.1
59.8
69.3
70.0
63.3
70.4
69.7
62.2
72.9
68.9
71.2
71.5
53.7
53.3
59.2
60.1
69.9
70.5
71.4
70.4
71.3
63.8
67.4
58.2
62.1
54.0
72.3
63.5
63.8
67.4
70.7
72.5
71.8
55.0
62.8
62.2
52.5
55.9
69.9
58.9
Total
population
estimate
(years)
61.4
72.2
61.0
71.4
57.2
60.7
71.1
64.3
64.6
66.6
67.6
68.4
69.8
64.1
71.1
72.0
64.4
71.8
71.0
64.9
72.8
69.8
71.4
72.7
55.9
55.3
62.8
63.3
71.5
71.0
72.9
71.2
72.0
65.8
69.2
59.8
63.1
58.6
73.4
63.8
66.2
69.5
72.6
73.3
73.2
54.7
63.4
62.0
54.4
59.2
70.6
59.4
a
The former Yugoslav Republic of Macedonia
Source: The world health report 2004 – Changing history (19).
Nevertheless, as mentioned, the DALY-based structure guides this report’s analysis, as it
offers a strong message about the priorities at a Region-wide level. The section on the major
causes of the burden of disease focuses on the three leading groups of conditions listed above,
including the seven leading conditions. The next section presents evidence on the seven
OVERVIEW
leading risk factors, ranked according to their
attributable share of total DALYs.
Condition
Total DALYs
(%)
10.5
6.2
7.2
3.1
2.3
2.4
2.2
33.8
1. Ischaemic heart disease
2. Unipolar depressive disorders
3. Cerebrovascular disease
4. Alcohol-use disorders
5. Chronic pulmonary disease
6. Road traffic injury
7. Lung cancer
Total
19
Table 4. Shares
of seven leading
conditions in the
DALY burden in
the WHO European
Region, 2002
Two issues: levels of certainty and
interrelationships between risk factors
Before this schema can be followed, however,
Source: The world health report
two additional issues must be addressed.
2004 – Changing history (19).
While the information above is robust at the
level of the Region and the country groups (EurTable 5. Shares of
Risk factor
Total DALYs
(%)
A, -B and -C), the estimates are less certain at
seven leading risk
12.8
A.
High
blood
pressure
factors in the DALY
the level of individual countries because of the
12.3
B. Tobacco
burden in the WHO
limitations of the currently available data at this
10.1
C. Alcohol
European Region,
8.7
D. High blood cholesterol
level and the assumptions in the epidemiological
2000
7.8
E. Overweight
modelling. Nevertheless, country-level
4.4
F. Low fruit and vegetable intake
Source: The world health
disaggregates of burden of disease estimates, and
3.5
G. Physical inactivity
report 2002 – Reducing risks,
59.6
Total
promoting healthy life (20).
of comparative estimates of attributable risk,
have been produced for this report. These are
ranked by the proportion of deaths and DALYs attributable to each cause and risk factor, and
the top 10 causes and risk factors for each country in the Region are presented in Annex Tables
4 and 5. These should help to give a better understanding of the health situation in individual
countries and country groups, and to design further analyses, strategies and intervention
programmes.
The country estimates for risk factors are based on the comparative risk assessment analyses
carried out for The world health report 2002 (20), but with updated country burden and
country-specific exposure data for around four of the risk factors. For most risk factors, either
the data for average exposure for the country groups or the overall disease-specific population
attributable fractions (PAFs) for the country groups were used at the country level. In particular,
the country-specific alcohol exposures are based on a preliminary adjustment of subregional
consumption distributions, using country estimates of abstainers and apparent consumption
per head. Thus, the attributable mortality and burden estimates, while based on the best
information currently available, usually have more uncertainty at the country level than that of
the Region, and could be improved with better country-specific exposure estimates. Ezzati et al.
(18) published the detailed methods and data for these risk factors.
In addition, the reader should remember that the risk factors and conditions are interrelated.
Individual risk factors are linked to different proportions of the total burden in DALYs. Purely
Conditions
63
33
28
22
27
23
12
9
4
3
2
8
69
38
85
H. Other
known factors
G. Physical
inactivity
22
F. Low fruit
and vegetable
intake
72
0.2
3
0
100
E. Overweight
and obesity
22
D. High
cholesterol
58
C. Alcohol
B. Tobacco
Ischaemic heart disease
Unipolar depressive disorders
Cerebrovascular disease
Alcohol-use disorders
Chronic pulmonary disease
Road traffic injury
Lung cancer
A. High blood
pressure
1.
2.
3.
4.
5.
6.
7.
Factors’ individual PAFs (%)
11
Table 6. Average
contribution of
the seven major
risk factors to the
disease burden
from the seven
major conditions
in developed
countries
worldwide
Source: adapted from
Ezzati et al. (21).
20
T H E E U R O P E A N H E A LT H R E P O R T 2 0 0 5
arithmetically, the sum of the DALYs attributable to each of the risk factors individually
amounts to three fifths of the total in the Region. This does not mean that the joint impact of
those risk factors on the population’s health amounts to three fifths of the total DALYs. It is less,
because several diseases are caused by more than one risk factor, and each factor contributes to
more than one condition.
Technically, the impact of each risk factor on the population’s health is measured by the
PAF in DALYs or deaths. This is the proportion of the disease burden on the population that
would be eliminated if the current exposure to the risk factor were reduced to the minimum
feasible. Table 6 shows the estimated PAFs of the seven leading risk factors as related to the
DALY burden of each of the seven leading conditions, on average, for the developed countries
in the world. The individual PAFs of two or more risk factors can add up to a joint PAF, which
is smaller than the sum of its parts. In essence, joint PAFs need to be calculated to estimate
the simultaneous effect of several risk factors. WHO estimates that the joint PAF for the many
known risk factors for NCDs in the WHO European Region is about 41–42% of the DALYs and
54–57% of the deaths caused by NCDs (18). Fig. 3 presents the 15 most significant known risk
factors.
Interventions addressing the seven leading risk factors can largely prevent the seven leading
conditions. This creates a compelling argument for making every effort to implement the
available knowledge and strategies to reduce these risks to the minimum possible. WHO’s
recent, more precise analyses (21) conclude that the potential health gain from controlling them
is greater than previously estimated.
Fig. 3. Proportions of total DALYs
that can be attributed to the
leading 15 known risk factors in the
WHO European Region, 2000
Elevated blood pressure
12.8
Tobacco use
12.3
Alcohol use
10.1
High cholesterol
8.7
Overweight
7.8
Low fruit and vegetable intake
4.4
Physical inactivity
3.5
Illicit drugs use
1.5
Lead exposure
0.8
Occupational risk for injury
0.7
Iron deficiency
0.7
Unsafe sex
0.7
Urban air pollution
0.6
Unsafe water and sanitation
0.5
Indoor smoke
0.4
0
Source: data from The world health
report 2002 – Reducing risks,
promoting healthy life (20).
2
4
6
8
Percentage
10
12
14
MA JOR C AUSES OF THE BURDEN OF DISEASE
21
Major causes of the burden of disease
The overview of the relationships of the leading
individual causes of and risk factors for the burden
of disease leads to this review of three main types
of conditions in the Region. The grouping of the
conditions and their sequence in the review are
based on the following considerations.
NCDs are responsible for 77% of the Region’s
disease burden. With the long time-lag between
exposure and manifestation, they require longterm planning and treatment. While accounting
for a far smaller share of the burden, injuries
are a particular problem for young people.
Communicable diseases affect the fewest people,
1. NCDs are responsible for 77% of the burden in
but attention needs to be paid to stop their spread
DALYs, with years of life lost due to premature
into the Region’s population at large. And poverty
mortality (YLL) accounting for 39% of the total
and underfunded services create a double burden
burden in 2002 and years lived in disability
of noncommunicable and communicable diseases
(YLD), 38%. NCDs are therefore a priority for
for some countries.
all countries. They are characterized by a long
time-lag between exposure and manifestation,
and usually require life-long observation and treatment. Both incidence and severity,
however, can be reduced in a relatively short time: improvements occur some 2–7 years after
eliminating exposure to a risk factor.
2. Injuries account for 14% of DALYs (10% YLL and 4% YLD), but place a very high burden of
disease on younger people and have severe social consequences. They are largely preventable
through changes in both the physical environment and prevailing norms of behaviour and
social cooperation (intolerance of violence, solidarity, etc.).
3. Communicable diseases are responsible for 9% of DALYs (6% YLL and 3% YLD). The time
between exposure and occurrence is short,
however, and epidemics can develop very fast,
Fig. 4. Proportional burden of disease in the WHO
European Region, 2002
endangering the health of large populations.
Fig. 4 illustrates the proportions of the overall
burden of disease in the WHO European Region.
NCDs
In 2002, NCDs caused 8.1 million deaths (85.8%
of total deaths) in the WHO European Region and
115.3 million DALYs (76.7% of the total disease
burden).
Table 7 presents the deaths and DALYs caused
by the main groups of NCDs in the WHO
European Region in 2002, and shows that their
ranking differs between the two measures. In
terms of mortality, the leading NCDs in the
Region were cardiovascular diseases (CVD) and
cancer, followed by the considerably smaller
groups of respiratory diseases, digestive diseases
Communicable diseases
Injuries
YLD
(4%)
YLL
(6%)
YLD
(3%)
YLL
(10%)
YLL
(39%)
YLD
(38%)
NCDs
22
Table 7. Deaths (in
thousands) and
burden of disease
(in thousands
of DALYs) from
NCDs in the WHO
European Region
by cause and
mortality strata,
2002
Source: The world
health report 2004
– Changing history (19).
T H E E U R O P E A N H E A LT H R E P O R T 2 0 0 5
Group of causes
Eur-A
Deaths
CVD
Neuropsychiatric disorders
Cancer
Digestive diseases
Respiratory diseases
Sense organ disorders
Musculoskeletal diseases
Diabetes mellitus
Other NCDs
Total for NCDs
Total for all causes
1 612
185
1 038
182
220
0
20
92
140
3 489
3 920
DALYs
8 838
13 732
8 549
2 414
3 406
2 465
2 197
1 105
3 489
45 091
51 725
Eur-B
Deaths
1 052
24
291
76
72
0
2
29
44
1 590
1 865
Eur-C
DALYs
8 175
7 055
3 289
1 900
1 547
1 589
1 513
566
1 590
27 441
37 697
Region
Deaths
DALYs
Deaths
DALYs
2 263
47
504
131
112
0
4
21
49
3 131
3 779
17 405
8 562
5 322
3 082
1 782
2 167
1 924
522
3131
42 807
60 900
4 927
256
1 833
389
404
0
26
142
233
8 210
9 564
34 418
29 349
17 160
7 396
6 735
6 221
5 634
2 193
8 210
115 339
150 322
and neuropsychiatric disorders. In terms of DALYs, however, CVD remained first but
neuropsychiatric disorders ranked ahead of cancer.
Leading NCDs
Table 8. Mortality
from ischaemic
heart disease: levels,
ranges and trends in
the WHO European
Region
Source: European health
for all database (3).
The seven leading conditions (see Table 4) include six NCDs: ischaemic heart disease,
depressive disorders, cerebrovascular disease, alcohol-use disorders, chronic respiratory
diseases and lung cancer. As trends over time in DALYs are not available, an approximation of
the trends in the burden from some diseases in the Region is inferred from trends in mortality.
This did not seem appropriate for depression and alcohol-use disorders, however, where the
mortality components of DALYs are much smaller and less indicative of the time trends in the
overall disease burden. For the latter two causes, a general situation assessment is given.
Since 1990, mortality from ischaemic heart disease has declined in Eur-A, but increased in
Eur-B and -C, albeit with considerable fluctuations and differences between countries (Table 8).
Depression is a major cause of death and disability in all countries. It is the most frequent
mental health problem, is responsible for most suicides and has considerable negative impact
on functioning and quality of life, as well as a considerable financial burden. The indirect
costs to society as a whole have been estimated to be seven times the direct costs. In western
Europe, major depression affects 5–10% of people at any point in time. Owing to non-specific
complaints, underdiagnosis is common. For example, depression is not recognized in about
50% of people in primary care.
Among the countries in the European Region reporting suicide to WHO, the highest rates
are found in eastern countries, such as Lithuania (40 per 100 000 population), the Russian
Federation (34 per 100 000)
and Belarus (33 per 100 000).
Deaths per 100 000, 2002
Change in
Country group
1990–2002
Nevertheless, the Eur-A average (31
Average
Country range
(%)
levels
(lowest–
per 100 000) is nearly three times
highest)
Eur-A
those for Eur-B and -C (around 11
–27.9
64–179
95.86
Total
per 100 000).
–26.4
44–134
66.13
Females
Suicide rates tend to increase
–29.6
88–210
135.39
Males
Eur-B
with age. On average, the rates in the
9.4
108–424
249.12
Total
Region for people aged 75 and older
15.3
75–351
200.92
Females
3.9
142–515
310.88
Males
are about twice those of people aged
Eur-C
15–29. This trend holds for both
29.6
222–592
418.15
Total
sexes, but suicide levels among males
23.2
171–517
309.03
Females
32.1
293–718
590.24
Males
are 3–4 times those for females.
MA JOR C AUSES OF THE BURDEN OF DISEASE
23
Table 9.
While depression and other
Deaths per 100 000, 2002
Change in
Country group
Mortality from
1990–2002
neuropsychiatric disorders clearly
Average
Country range
(%)
cerebrovascular
levels
(lowest–
cause an enormous burden, major
highest)
disease: levels,
Eur-A
ranges and trends
improvements in policy and services
–32.3
54–145
61.15
Total
in the WHO
are taking place (see success story).
–32.4
49–126
55.71
Females
European Region
Cerebrovascular disease is steadily
–32.8
60–173
68.05
Males
Eur-B
declining in Eur-A countries (Table 9).
7.1
88–272
153.04
Total
In Eur-B, it increased in the early 1990s, Females
6.7
73–247
139.62
6.3
109–298
168.85
Males
but stabilized in recent years and may
Eur-C
now be decreasing. In Eur-C, levels rose Total
16.6
122–307
258.11
considerably in the early 1990s, with
12.6
112–270
227.12
Females
Source: European health
17.5
137–359
302.66
Males
for all database (3).
fluctuations, and show no reversal.
Alcohol-use disorders are part of
Table 10. Mortality
the group of neuropsychiatric
Deaths per 100 000, 2002
Change in
Country group
1990–2002
from chronic
conditions. They include the direct
Average
Country range
(%)
respiratory
levels
(lowest–
burden of alcohol dependence and
highest)
diseases: levels,
Eur-A
harmful use due to conditions such
ranges and trends
–24.2
14–29
20.2
Total
in the WHO
as alcohol psychoses and dependence
–12.6
5–45
13.0
Females
European Region
syndrome, and acute intoxications
–31.4
14–49
32.5
Males
Eur-B
due to excessive drinking. They do not
–23.3
7–95
26.4
Total
include the burden of other diseases or
–22.6
6–82
17.7
Females
–23.9
9–164
39.3
injuries where alcohol is a causal factor. Males
Eur-C
The analysis of The world health
–12.1
11–53
34.8
Total
report 2004 (19) found that the burden
–28.6
5–40
16.6
Females
Source: European health
–6.7
23–105
69.6
Males
for all database (3).
of disease attributable to alcohol-use
disorders was 4.6 million DALYs in the
European Region in 2002: 3.1% of the total. Alcohol-use disorders are directly responsible for
about 37% of total alcohol-attributable DALYs, but the proportion is lower for deaths, because
these disorders result in considerable non-fatal loss of health. By all measures, the burden is 4–5
times higher in males than females. As to the disability component of the burden, however, the
levels in males are about the same in all three country groups and seem to be falling, while those
in females seem to be rising.
Overall, mortality from chronic respiratory diseases has steadily fallen in the Region as a
whole and in Eur-A and -B countries since 1990. In Eur-C, death rates rose considerably and
peaked in the early 1990s, but then dropped to pre-1990 levels (Table 10).
Cancer was responsible for around 18% of all deaths in the Region in 2003. Since 1990, trends
have showed a general decline in all parts of the Region. This trend is also seen for the leading
cause: lung cancer, which is responsible for 22% of all cancer deaths in the Region. The overall
downward trend in lung cancer deaths, however, was due to decreases in males, while deaths
rose in females in Eur-A and -B (Table 11), largely owing to smoking. As the prevalence of
smoking among women remains high and is probably rising in eastern Europe, the death toll
from lung cancer is likely to increase unless rates of smoking cessation improve rapidly.
Injuries
Intentional and unintentional injuries continue to be a considerable public health problem,
largely underestimated and even neglected in many countries. One of the main reasons for the
24
T H E E U R O P E A N H E A LT H R E P O R T 2 0 0 5
Table 11.
Mortality from
lung cancer:
levels, ranges
and trends in the
WHO European
Region
Source: European
health for all
database (3).
Country group
Eur-A
Total
Females
Males
Eur-B
Total
Females
Males
Eur-C
Total
Females
Males
•
•
Deaths per 100 000, 2002
Change in
1990–2002
(%)
Average
levels
Country range
(lowest–
highest)
37.06
16.39
63.88
23–47
6–30
42–88
–7.4
21.0
–16.1
31.67
11.29
58.39
10–53
4–20
16–101
–3.8
13.7
–6.7
36.23
9.28
79.16
24–63
5–32
46–112
–17.4
–16.6
–19.8
problem is actually relative ignorance
of both its size and the effective
interventions available to deal with it
(such as that in the success story below).
In the WHO European Region,
injuries are estimated to have caused
21 million DALYs in 2002 (Table 12).
Unintentional injuries accounted for 14.5
million DALYs (69%) and intentional
injuries, 6.5 million (31%).
The ranking of the leading causes of
DALYs lost from injuries differs between
country groups. The leading causes are:
road traffic injuries, self-inflicted injuries, falls, violence and poisoning in Eur-A and -B; but
self-inflicted injuries, violence, poisoning, road traffic injuries and falls in Eur-C.
The escalation of violence and poisoning in Eur-C must be seen in context: overall rates
of injuries in terms of DALYs are five times higher in Eur-C than Eur-A. Levels in Eur-B are
twice those in Eur-A. This steep gradient in destructive and self-destructive health-related
behaviour suggests that the eastern half of the Region has greater need for strategies to prevent
injuries and violence, and that all such strategies in the Region should be tailored to the specific
characteristics of both physical and social environments, and the cultural background of risktaking behaviour.
SUCCESS STORY
Improving mental health in The former Yugoslav Republic
of Macedonia: from hospital to the community
In The former Yugoslav Republic of Macedonia, people
with serious mental illnesses were traditionally viewed
as unable to participate in community life. Independent
living, and having a job and a social life were considered
beyond their capacities. It was also believed that they
needed prolonged treatment in a psychiatric hospital.
The mental health reforms in 2000 opened a
new window. Attitudes started to shift away from
custodial care towards treatment in the community.
The WHO mental health project (22), involving the
WHO Country Office, supported these reforms.
These changes enabled the creation of another
kind of service through the transformation of the big
psychiatric hospitals. Community mental health centres
were established in four cities: two in Skopje (the capital)
and one each in Tetovo, Prilep and Gevgelija. For the
first time, protected apartments in three cities in the
country were created to enable people with long-term
illnesses to live with their neighbours in the community.
The opening of a social cooperative (a cleaning service
and hairdresser) gave people with mental illnesses
the chance to enter the labour market. To strengthen
the role of service users, work began to start three
social clubs and nongovernmental institutions.
Real political commitment to the country’s mental
health reforms is supported through the intersectoral
National Commission for the Protection of Mental
Health, which was established in May 2003 under the
auspices of the Minister of Health. The national policy,
operational action plan and mental health legislation
were finalized. The policy and legislation are being
submitted for endorsement by the Government.
The new mental health services started changes in
the community. Transformation of the treatment system
helped to change views on care in the community. The
creation of the alternative services initiated a process
that facilitates dynamic relationships between different
groups and institutions, followed by the process of
discussion, agreement and disagreement and finally
consensus between different stakeholders: governmental
and nongovernmental bodies, service users, families,
professional institutions and international organizations.
The process is long and the story still unfolding.
MA JOR C AUSES OF THE BURDEN OF DISEASE
Group of causes
Eur-A
Deaths
Unintentional injuries
Road traffic injuries
Poisoning
Falls
Fires
Drowning
Other
Intentional injuries
Self-inflicted injuries
Violence
War
Total for all causes
Total for all causes
(in rates per 1000 population)
137
46
6
47
3
4
32
53
48
4
0
190
0.5
Eur-B
DALYs
3 042
1 233
126
615
57
74
937
1 039
890
134
14
4 081
9.8
Deaths
76
22
6
9
3
6
31
33
23
8
2
110
0.5
Eur-C
Region
DALYs
Deaths
DALYs
Deaths
DALYs
3 123
641
126
481
153
167
1 556
935
532
255
130
4 058
18.2
321
59
99
24
18
28
94
170
92
61
17
492
2.1
8 317
1 732
1 885
939
425
649
2 686
4 489
1 969
1 912
605
12 806
53.4
534
127
110
80
24
38
156
257
164
73
19
791
0.9
14 482
3 606
2 137
2 035
635
890
5 179
6 463
3 391
2 301
749
20 945
23.9
25
Table 12. Deaths
(in thousands)
and burden
of disease (in
thousands of
DALYs) from
injuries in the
WHO European
Region by cause
and mortality
strata, 2002
Source: The world health report
2004 – Changing history (19).
In particular, the overall proportion of DALYs due to injuries is nearly twice as high for males
as for females, although there are differences by type of injury. This gender difference emerges
in early childhood. To target preventive actions, the authorities therefore need to understand
and take account of a number of factors: the specific characteristics of gender roles, the related
risk-taking behaviour, and the risk and contributing factors related to each type of setting
and injury in the country: for example, the time of occurrence, type of family or professional
background of the affected people, etc. Moreover, the death and disability toll is directly related
to poverty and socioeconomic deprivation. Worldwide, by 2020 injury rates are expected to
drop by 30% from 2000 levels in higher-income countries, but rise by 80% in poorer countries,
if current trends continue (23).
Road traffic injuries are among the 10 leading causes of the disease burden in all parts of
the Region. In 2002, such injuries accounted for 3.0 DALYs per 1000 population in Eur-A, and
2.9 and 7.2 DALYs per 1000 in Eur-B and -C, respectively. As mentioned, this indicates that
different types of phenomena and risk factors in countries, which require detailed analysis, may
lie behind these figures.
Trends in mortality from all types of traffic injury – which are likely to be more comparable
across the Region – peaked around 1990 in all country groups, but steadily decreased
afterwards in Eur-A and -B. Eur-C experienced a decrease until 1997, after which deaths
increased for six years in a row but remained below the peak of 30 per 100 000 in 1991.
The reasons may be that economic recovery was not accompanied by improvements in
infrastructure and driving behaviour, as preventive programmes were not fully implemented.
Pedestrians are killed in traffic more often in Eur-B and -C than in Eur-A. Mortality from
motor-vehicle traffic injury shows a similar trend, falling from 25 per 100 000 in 1991 to 16 per
100 000 in 1997 and then more or less levelling off at 18 per 100 000 (Table 13).
The economic toll of traffic accidents is also high: estimated to be about 2% of GDP per
year in some western countries of the Region. Yet some effective control measures – such as
enforcing laws against drink–driving, and requiring cyclists to wear helmets and motor-vehicle
occupants to wear seat-belts – are not very expensive.
The success of some Member States in reducing the toll from road traffic injuries reconfirms
that the key is political commitment and comprehensive measures (see success story). The
health sector should use this experience as an opportunity to review and perhaps enhance its
role and responsibilities as a partner of the other sectors involved, such as transport, finance, the
judiciary and the environment (24).
26
T H E E U R O P E A N H E A LT H R E P O R T 2 0 0 5
Table 13.
Mortality from
motor vehicle
traffic injury:
levels, ranges
and trends in the
WHO European
Region
Source: European health
for all database (3).
Country group
Eur-A
Total
Females
Males
Eur-B
Total
Females
Males
Eur-C
Total
Females
Males
•
•
Deaths per 100 000, 2002
Change in
1990–2002
(%)
Average
levels
Country range
(lowest–
highest)
9.9
4.64
15.38
4–19
1–8
7–22
–29.6
–32.8
–29.1
9.88
4.45
15.78
6–14
3–6
10–23
–47.8
–42.2
–49.2
17.92
8.7
28.45
12–23
6–10
20–38
–26.6
–12.5
–30.1
Communicable diseases
Communicable diseases account for
9% of the disease burden measured
in DALYs, a little over half of which
is related to HIV and tuberculosis
(TB), but this should not be the main
criterion for judging their public health
importance. Communicable diseases
remain important owing to:
•
the high rates of TB and growing
rates of HIV infection in several
countries, particularly in the CIS;
the continuing threat from other, mainly epidemic-prone, communicable diseases; and
the emergence of new diseases.
The WHO European Region reported 34 cases of severe acute respiratory syndrome (SARS)
in 10 countries, indicating how the globalization of trade and travel has put the Region at risk
of importing both new and re-emerging diseases. New pathogens will continue to emerge and
Preventing road-traffic accidents in Sweden
SUCCESS STORY
The Vision Zero project in Sweden is a traffic safety
policy developed in the late 1990s and based on four
elements: ethics, responsibility, a philosophy of safety and
creating mechanisms for change. The Swedish Parliament
voted to adopt this policy in October 1997. Since then,
several other countries have followed the example.
Ethics
Human life and health are paramount. According to
Vision Zero, life and health should not be allowed in
the long run to be traded off against the benefits of
the road transport system, such as mobility. Mobility
and accessibility are therefore functions of the
inherent system, not vice versa, as is usual today.
Responsibility
Until recently, responsibility for crashes and injuries
was placed principally on the individual road user.
In Vision Zero, responsibility is shared between the
users and providers of the system. The designers and
enforcers of the system – such as those providing the
road infrastructure, the automobile industry and the
police – are responsible for its functioning. At the same
time, the road user is responsible for following basic
rules, such as obeying speed limits and not driving while
under the influence of alcohol. If users fail to follow
such rules, the system designers are responsible for
redesigning the system, including rules and regulations.
Safety philosophy
As with accidents and injuries, the responsibility
for safety formerly lay with the road user. Vision
Zero has an outlook that has been successfully
used in other fields. Its two premises are that:
• human beings make errors; and
• there is a critical limit beyond which survival and
recovery from an injury are not possible.
The road transport system should be able to take account
of human failings and absorb errors in such a way as to avoid
death and serious injuries. The occurrence of crashes and
even minor injuries, on the other hand, needs to be accepted.
Creating mechanisms for change
Changing the system involves acting on the
first three elements of the policy. The main
measures taken in Sweden include:
• setting safety performance goals for various
parts of the road traffic system;
• a focus on crash protection for vehicles, and support
•
•
•
•
•
•
for the consumer information programme of the
European New Car Assessment Programme;
securing higher levels of seat-belt use and fitting
smart, audible seat-belt reminders in new cars;
installing crash-protective central barriers
on single-carriageway rural roads;
encouraging local authorities to create zones
with a speed limit of 30 km per hour;
wider use of speed cameras;
an increased number of random breath tests; and
the promotion of safety as a competitive
variable in road transport contracts.
Source: World report on road traffic injury prevention (23).
MA JOR C AUSES OF THE BURDEN OF DISEASE
can quickly become a public health threat on all continents. The risk of terrorist attacks using
biological agents adds to the risks of the natural occurrence of communicable diseases.
Factors that increase the epidemiological risks and create the double disease burden borne
by some countries include poverty and underfunded government services that reduce people’s
access to basic sanitation and hygiene, healthy and safe food and drinking-water, and preventive
and curative health services.
All Member States need the capacity to detect, analyse and contain threats from
communicable diseases. In recent years, surveillance systems have been systematically
reviewed. The results can be summarized as follows.
In Eur-A, the surveillance systems are mostly well developed, including complex, sometimes
Internet-based reporting systems. Early warning systems are usually well developed. Recent
policies of decentralization, however, mean that not all epidemiological information is available
on time at the national and international levels. The surveillance systems in most of the new EU
members are a mix of systems typical of either the CIS or western European countries. They are
well designed and based on international case definitions. Many countries, however, need to
review their outdated national legislation on communicable diseases.
In Eur-B and -C, the level of development of surveillance systems varies widely. Some
countries used to have well-developed systems that combined human surveillance with
surveillance of environmental determinants. The transition from centralized to market
economies, and civil unrest, however, mean that many of these systems are no longer sustained
and have practically collapsed. Very few communicable disease programmes supported by the
international community have maintained their effectiveness. The CIS countries have probably
suffered the most from the transition, and their surveillance systems almost totally lack the
required infrastructure. Where surveillance systems are operating, local health systems do not
systematically use the information gained for decision-making and give little feedback on the
collected data and reports. In addition, laboratory capacity in several CIS countries is much too
limited.
HIV/AIDS
HIV/AIDS is fast becoming a major threat to health, economic stability and human
development in many parts of the WHO European Region (25). WHO and the Joint United
Nations Programme on HIV/AIDS (UNAIDS) estimate that, at the end of 2003, 1.88 million
people were living with HIV/AIDS in the WHO European Region, 1.3 million of them in the
CIS (26). Estimated HIV prevalence in adults exceeded 1% in three countries – Estonia, the
Russian Federation and Ukraine (26). These three, and Latvia, have some of the highest HIV
rates in the world.
The HIV/AIDS epidemic in the Region shows important differences between groups of
countries. In western Europe, peaks in HIV incidence in 1983 (among men who had sex
with men) and 1987/1988 (among injecting drug users) gave way to a period of relative
decline and stability. Unfortunately, the rate of newly diagnosed HIV infections is once again
increasing (27). Infections through heterosexual contact increased markedly in 2002 and
2003, mostly due to cases diagnosed in people from countries with generalized epidemics
– mainly in sub-Saharan Africa – who were probably infected there (28). Western European
countries experiencing such increases include Belgium, Denmark, Germany, Ireland, Sweden,
Switzerland and the United Kingdom (28). Cases among men who have sex with men also
increased in western European countries in 2002 and 2003 (28). Following the introduction
27
28
T H E E U R O P E A N H E A LT H R E P O R T 2 0 0 5
and widespread use of highly active antiretroviral therapy (HAART) in these countries, AIDS
incidence and deaths declined sharply in the mid/late-1990s (29) and continue to fall, albeit
with a noticeable levelling off after 1998. Recent increases in HIV and AIDS in some western
European countries raise concerns about the vulnerability of migrants, increased risk behaviour
among men who have sex with men, treatment complacency (in which people resume risk
behaviour because the disease is treatable), weakening government commitment and waning
prevention efforts.
In central and eastern European countries, the overall rates of both newly diagnosed HIV
infection and AIDS remained relatively low and unchanged in recent years. Around 21 000 new
HIV infections were reported in this region by the end of 2003. Three quarters of all cases are
in Romania and Poland. In the same period, 12 791 cases of AIDS and 5869 AIDS deaths were
reported (27). Trends in newly reported HIV cases and AIDS deaths have stabilized over the
past decade, while numbers of reported AIDS cases have declined slowly in the last six years.
High levels of risk behaviour, low levels of knowledge and poorly developed prevention and
treatment services in some countries are preconditions for potentially devastating HIV/AIDS
epidemics (30).
In the Baltic states and many CIS countries, more than 80% of reported HIV cases are in
injecting drug users (31). Well-documented HIV epidemics among injecting drug users have
been reported in Belarus, Estonia, Latvia, Lithuania, Kazakhstan, the Republic of Moldova, the
Russian Federation and Ukraine. In the Russian Federation, new HIV infections doubled every
6–12 months between 1995 and 2001 (see success story for one republic’s response). In addition,
these countries have the highest incidence of TB and multidrug-resistant TB in the Region.
TB/HIV co-infection is associated with higher morbidity and mortality and increased TB
transmission to the general population. In the Russian Federation, TB was estimated to cause
35% of deaths in adults with AIDS in 2000 (32).
SUCCESS STORY
HIV prevention and harm reduction programmes
in the Russian Federation: the Renewal project
in the Republic of Tatarstan
An increasing number of regions in the Russian
Federation include HIV harm-reduction programmes in
their disease prevention strategies, targeting diseases of
public health concern. This shows that HIV prevention
activities can be incorporated in existing infrastructures,
which are not dependent on funding from donors.
An example is the Renewal project, which started
small in 1999 in the Republic of Tatarstan with external
financial support, and developed into a Republic-wide
harm-reduction programme implemented in nine cities
with regular-budget funding. Early on, the project gained
the support of ministries other than the health ministry,
particularly the interior ministry. The project focuses
on injecting drug users, sex workers and prisoners. The
interventions include: needle-exchange programmes;
distribution of condoms, antiseptic and other materials;
information, education and outreach activities; free and
anonymous HIV testing, sexually transmitted infection
testing and treatment; and other medical consultations.
In 2004, the harm-reduction programme started TB
diagnosis and treatment, including support for adherence
to treatment and directly observed TB treatment.
A good understanding of the needs and living
circumstances of the target populations benefited the
design and implementation of the project. Most important,
however, the attitudes of the law enforcement services
towards these highly vulnerable groups have changed
from repressive to supportive. In 2002, the harm-reduction
programme was legally sanctioned by the government of the
Republic of Tatarstan. The annual rates of newly registered
HIV cases decreased by factors of 1.9 in 2002 and 1.6 in 2003.
MA JOR C AUSES OF THE BURDEN OF DISEASE
Malaria
Overall, malaria is under control but political will is decisive in maintaining and improving
the situation. Ten countries in the Region have been affected by malaria in the last two decades
(33–37). The number of malaria cases rose from 8884 in 1990 to 90 506 in 1995 and then fell to
37 170 in 1999. The latest available figure (15 983 cases in 2003) shows a continued decline.
Malaria re-emerged in countries in the Caucasus and central Asia, owing to the considerable
political and socioeconomic changes and the resulting movements of population, extensive
development projects and the practical discontinuation of malaria prevention and control
activities in the early 1990s. The real magnitude of the problem is uncertain. The affected
countries in the Region will continue to face the risk of growing malaria-related public health
problems, unless both countries and the international community make a sustainable effort to
control the disease.
TB
TB is the leading communicable-disease killer of young adults in the European Region (38–41).
Most cases are in people aged 15–54 years, with the peak among those aged 45–54 years. The
rate among males is three times that in females. The trends in the epidemic are comparable to
those in the African countries most affected by HIV/AIDS; the number of reported new cases in
the Region rose from 231 608 in 1991 to 360 741 in 2003 (42).
The situation is critical in the Baltic states, the CIS and Romania. These 16 countries have
four fifths of all cases notified in the Region. TB is a public health concern, however, in other
countries with an intermediate or low TB burden, where the decline in notification rates has
levelled off as a result of war, civil conflict and instability, or the emergence of high-risk groups
among immigrants.
The major factors behind the epidemic are poverty, multidrug-resistant TB (MDR-TB), HIV
co-infection and the spread of TB in prison populations.
Evidence of what works is categorical. Recalling World Health Assembly resolution
WHA53.1 (43), which recognized that the global TB burden is a major impediment to
socioeconomic development and a significant cause of premature deaths and human suffering,
the WHO Regional Committee for Europe (40) in September 2002 called for:
•
•
accelerated implementation of the strategy of directly observed treatment, short-course
(DOTS) to achieve the global targets by 2005 (70% detection of infectious TB cases and 85%
treatment success) and to prevent new MDR-TB cases; and
implementation of the DOTS-Plus strategy to manage MDR-TB in countries with high rates.
The main barriers to the successful implementation of this proven strategy are a lack of
political commitment in some countries, a lack of funds and weaknesses in the public health
infrastructure.
29
30
T H E E U R O P E A N H E A LT H R E P O R T 2 0 0 5
Major preventable risk factors
As mentioned, just seven risk factors are responsible
Just seven risk factors are
for most of the burden of disease from NCDs in
responsible for the majority of NCDs
the WHO European Region: high blood pressure,
in the WHO European Region: high
tobacco use, harmful and hazardous alcohol use,
blood pressure, tobacco, alcohol,
high cholesterol, being overweight, low fruit and
high cholesterol, being overweight,
low intake of fruits and vegetables,
vegetable intake, and physical inactivity. They
and physical inactivity.
occupy the top ranks in terms of attributable DALYs
(Annex Table 5) in each of the three country groups.
To reduce these risk factors
They are also the top seven preventable risk
coordinated, multifaceted,
multisectoral action needs to be
factors in most countries. There are two main
taken to change behaviour across
exceptions. First, the use of illicit drugs is among the
the Region.
leading seven risk factors in some western European
countries, mostly because low fruit and vegetable
intake ranks lower. Second, three environmental
factors of particular relevance for children’s health are among the leading seven risk factors in
the central Asian republics: unsafe water and sanitation, indoor smoke from burning of solid
fuels, and childhood and maternal underweight.
Effective approaches
Again, the combined effect of any group of known risk factors is often less than the sum of
their separate effects. Nevertheless, the multicausal nature of NCDs often gives countries
both a choice among different preventive strategies in terms of cost–effectiveness, and
opportunities for great potential benefit from simultaneous interventions. WHO estimates,
for example, that modest population-wide and simultaneous reductions in blood pressure,
obesity, cholesterol and tobacco use would more than halve CVD incidence (see success
story). The removal of the leading 20 risk factors known to be largely preventable would
lead to important gains in HALE: over 5 years, 8 years and 10 years in Eur-A, -B and -C,
respectively. This would considerably reduce the inequalities between countries.
These common risk factors have economic, social, gender, political, behavioural and
environmental determinants. The behavioural determinants have major mental health
components. All these determinants and factors need to be taken into account in the design
of cost-effective intervention strategies to prevent and treat NCDs.
While primary prevention is a more long-term task, real short-term gains can be made
in treating people at high risk, such as those with established coronary heart disease. More
needs to be done to ensure that those who would benefit from drug treatment receive the
support they need. Drugs such as beta-blockers, acetylsalicylic acid and lipid-lowering agents
can be highly effective in reducing the risks of CVD morbidity and mortality.
A combination of measures aimed simultaneously at both populations and individuals
at high risk of developing disease is also very important, as shown by the discussion below.
For example, positive evaluations were given to both types of measure to reduce CVD:
population interventions to reduce salt intake, cholesterol and body mass index, and the use
of the absolute risk approach, which aims interventions at individuals at high risk.
M A J O R P R E V E N TA B L E R I S K FA C T O R S
The following sections present data on the prevalence of the major NCD risk factors in the
Region. Priority should be given to controlling these risk factors where effective preventive
strategies are available. Interventions should take place at the individual as well as population
level. Individuals should be empowered and encouraged to make positive, health enhancing
decisions about, for example, the risks from smoking, alcohol consumption, an unhealthy diet
and unsafe sex. Reducing the burden of death and disability from NCDs by controlling these
risk factors requires a multisectoral approach that mobilizes the combined energy, resources
and expertise of all stakeholders. A balance must be struck between government, communities
and individual action, supported by nongovernmental organizations, the mass media and
others.
In May 2004, World Health Assembly resolution WHA57.17 (45) endorsed the Global
Strategy on Diet, Physical Activity and Health (46). It encourages governments to build on
existing structures and processes that already address aspects of diet, nutrition and physical
activity, and to set up national coordinating mechanisms that address these issues in the context
of a comprehensive plan for NCD prevention and health promotion. Resolution WHA57.17
sees industry as part of the solution, and recommends joint action with the food industry (45).
Consumers require accurate and clear information in order to make informed choices. Many
governments are revisiting their regulations on nutrition labelling and health claims, because
they see that claims based on scientific evidence can help promote healthy choices.
The health ministry has the responsibility to coordinate and facilitate the contributions of
other ministries and government agencies to a country’s health strategies. These contributors
include ministries and government institutions responsible for policies on food, agriculture,
SUCCESS STORY
Preventing NCDs in Finland
The North Karelia Project in Finland shows how, over a period
of 25 years, major changes took place in the levels of targeted
risk factors. Among the male population in the North Karelia
region, smoking declined greatly and dietary habits changed
markedly. The proportion of middle-aged men in North
Karelia who smoked fell from 52% in 1972 to 31% in 1997.
In the early 1970s, the use of vegetables or vegetable
oil products was very rare; now it is very common. In 1972
about 90% of the population in North Karelia reported
using mainly butter on bread. Today’s figure is less
than 7%. Such dietary changes have led to a reduction
of about 17% in the population’s mean level of serum
cholesterol. High blood pressure was brought well under
control and leisure-time physical activity increased.
Women made similar changes in their dietary habits
and cholesterol and blood-pressure levels, but smoking
increased somewhat, although from a low level.
These changes in risk factors extended well beyond the
original reference area, to be paralleled all over Finland.
In the 1980s, the trends in North Karelia levelled off, but
remarkable changes followed, particularly in dietary
changes to lower cholesterol. These were associated
with major reductions in serum cholesterol levels.
By 1995, the annual mortality for coronary heart
disease in middle-aged men (adults aged under 65
years) in North Karelia had fallen about 73% from the
rate in the years preceding the Project (1967–1971).
This reduction was especially rapid in the 1970s and
after the mid-1980s. Mortality from coronary heart
disease in men in North Karelia fell by about 8% per year
during the last 10 years. The reduction in mortality from
CVD among women was of the same magnitude.
After the 1980s, these favourable changes began
to develop all over Finland. By 1995, the annual
mortality from coronary heart disease among men
in Finland had fallen by 65%. Lung cancer mortality
also fell in this period, by more than 70% in North
Karelia and nearly 60% in Finland as a whole.
With greatly reduced CVD and cancer mortality,
all-cause mortality declined about 45%, leading also to
greater life expectancy: about 7 additional years for men
and 6 for women. Associated with favourable changes
in risk factors and lifestyles, people’s general health
greatly improved. A separate analysis showed that most
of the decline in mortality from coronary heart disease
can be explained by the change in the population
levels of the target risk factors, and that the reduction
in cholesterol levels was the strongest contributor.
Source: Successful prevention of noncommunicable diseases: 25
year experiences with North Karelia Project in Finland (44).
31
32
T H E E U R O P E A N H E A LT H R E P O R T 2 0 0 5
young people, recreation, sports, education, commerce and industry, finance, transport, the
mass media and communications, social affairs and environmental and urban planning (46).
Validated and comparable epidemiological data on these issues are scarce. Governments
are strongly encouraged to support data collection on risk factors across time and population
groups. Overall, prevalence levels seem to be slowly declining, as documented by data of the
MONICA (multinational monitoring of trends and determinants in cardiovascular disease)
project, which are limited in coverage but still one of the most uniform sources of such
information (47,48). With some additional information, the situation can be presented as
follows.
High blood pressure
High blood pressure is one of the most important preventable causes of premature death. People
with elevated blood pressure have a considerably higher risk of stroke, ischaemic heart disease,
other cardiac diseases and renal failure. This risk in turn is related to unhealthy diets, especially
high salt intake, insufficient physical exercise, excess body weight and risky alcohol use. High
blood pressure is found in both richer and poorer countries. In most countries, it is estimated
that up to 30% of adults suffer from high blood pressure and a further 50–60% would be in
better health if they reduced their blood pressure by increasing physical activity, maintaining
healthier body weight and eating more fruits and vegetables (49).
High blood pressure is the top-ranking risk factor in the European Region in terms of
attributable DALYs (12.8% of total DALYS). It is widely underestimated, and often ignored
as a problem. Data from the MONICA project show very large variations in blood pressure
levels between different populations. Fortunately, blood pressure levels appear to be falling in
considerably more populations than those in which they are rising. Countries should work
together to establish comparable databases to monitor this and other major risk factors.
Tobacco
Tobacco use has become the single biggest preventable cause of death. Smoking is the second
most important risk factor in the Region (accounting for 12.3% of total DALYs) and continues
to expand in poorer countries and disadvantaged socioeconomic groups.
Although current prevalence is only a proxy of past exposure, it provides a general indication
of the stage reached by a given population in the course of the smoking epidemic. While the
epidemic is slowing in western Europe, it is still growing in the countries in the eastern half of
the Region (50).
Half of tobacco users will die of a tobacco-related disease. The morbidity or impaired health
caused by tobacco is more widespread. As most of these deaths occur in middle age, the loss
of income and the effects of chronic illness severely affect the quality of life and well-being of
tobacco users’ families. In addition, smoking rates are highest among the poorest, who suffer
more than the rich from the consequences of tobacco use and have fewer resources to use in
coping with them.
All factors considered, tobacco use is a net loss to an economy. At the same time, public
health interventions to reduce smoking are highly cost-effective (see success story and key
points for decision-makers). Comparable data on the prevalence of smoking, however, are
rarely available. Countries are encouraged to collect reliable, valid and comparable data on
smoking – especially by gender, age and socioeconomic population groups – to enable better
targeting and monitoring of public health interventions.
M A J O R P R E V E N TA B L E R I S K FA C T O R S
SUCCESS STORY
Smoking cessation in Coventry, United Kingdom
Coventry’s smoking-cessation service is one of
the most successful in England, easily exceeding
Government targets every year for the last four
years and helping thousands of people break
the smoking habit. When the Government
introduced its targets in 2000, health mangers in
the city aimed to help 150–200 people a year.
The Coventry Teaching Primary Care Trust, which
oversees the service, found that more than 1800 people
who used the service between April 2003 and March
2004 stopped smoking after four weeks. Of these,
an estimated 700 will have quit smoking for good.
Since half of all smokers die from their habit, health
experts believe about 350 lives will have been saved.
In the last four years, the targets have increased
almost tenfold, and every year the smoking-cessation
team has exceeded them. Health managers say those
who quit for good benefit from a whole range of positive
effects, including saving an average £4.50 a day on
cigarettes. It is estimated that the 700 people who quit
smoking in the last year will have already saved more than
£1 million between them, much of which is spent locally.
Sources: Coventry Evening Telegraph (51) and Coventry
Teaching Primary Care Trust (52).
One very important tool to manage the tobacco epidemic is the WHO Framework
Convention on Tobacco Control (FCTC), the world’s first public health treaty (54). Ratification
by the fortieth WHO Member State, Peru, in November 2004 triggered the FCTC’s entry into
force in February 2005. The first 40 countries included 8 in the European Region: Armenia,
France, Hungary, Iceland, Malta, Norway, San Marino and Slovakia. The Region as a whole
played a very active role in the FCTC negotiation process, which started in 2000. The tasks
ahead include gaining the active participation of other countries and the implementation of the
FCTC.
Evidence-based assessment of key points for decision-makers: tobacco
Although tobacco deaths are on
the rise globally, control policies
have managed to reduce smoking
in some places. Millions of people
in the WHO European Region could
be spared disease and early death if
effective policies were put in place.
Raising the prices of tobacco
products is one of the most effective
means of reducing cigarette smoking.
A price increase of 10% results in a
2.5–5% smoking reduction in the
short run and possibly up to 10% in
the long run, if prices are increased
to keep pace with inflation. Young
people may reduce their smoking
at two to three times the rate of
older people. This level of response
could result in 0.5–2 million fewer
deaths from smoking in the betteroff, western half of the Region, and
in 0.6–1.8 million fewer deaths in
the less affluent eastern half. Some
countries have raised taxes to 70–80%
of the price of a pack of cigarettes,
resulting in significant reductions
in smoking, although smaller tax
raises have also been successful.
The most common concerns
about price increases are:
• that government revenues may
•
•
fall and jobs may be lost owing to
reduced tobacco consumption;
that smuggling may increase
dramatically; and
that an increase in price
disproportionately burdens
lower-income smokers.
Such consequences are either
false or overestimated. The
economic and health benefits from
increased tobacco prices appear
to outweigh any disadvantages.
The principal recommendation
for policy-makers is that tobacco
control programmes should be
comprehensive to maximize smoking
reductions, and should include:
• permanent price increases,
scaled to inflation;
• comprehensive bans on
promoting tobacco products;
• strong restrictions on smoking in
workplaces and public spaces;
• education and counteradvertising campaigns;
• improved product
warning labels; and
• increased access to cessation
therapies.
Different measures likely have
synergistic effects, and the consensus
is that comprehensive approaches
are the most effective means of
reducing tobacco consumption.
Source: Health Evidence Network (53).
33
34
T H E E U R O P E A N H E A LT H R E P O R T 2 0 0 5
Alcohol
Of all WHO regions, the European Region has the highest alcohol intake. The steady decrease
in alcohol consumption that began in the 1980s, stopped in the mid-1990s. Levels have not
changed since then.
The countries in the Region show a clear tendency towards harmonizing their consumption
levels towards the middle of the range. As a risk factor, alcohol consumption has two
dimensions: average volume and patterns of drinking. Average consumption figures hide
wide variations in individual consumption levels and drinking habits. The adverse effects of
drinking, however, are not confined to a minority of easily identified heavy or problem drinkers
or people dependent on alcohol. Many moderate or occasional drinkers also suffer from
alcohol-related problems, especially when they use alcoholic beverages as intoxicants.
Alcohol consumption produces effects that are often perceived as positive, but it has been
estimated to cause 5.5% of all the deaths and 10.1% of all DALYs in the Region, much higher
than the global estimates of 3.2% of all deaths and 4.0% of all DALYs being attributable to
alcohol (55–57). Eur-C has the highest alcohol-related burden of disease in the world. This
burden is far larger for men than women, and alcohol is the most important risk factor for
mortality and morbidity in young people.
Research indicates a causal relationship between alcohol consumption and more than 60
types of disease and injury. While evidence is accumulating that drinking might have positive
links to a few diseases, most notably ischemic heart disease, aggregate-level studies have failed
to corroborate this. In contrast to most other risk factors in developed countries – such as
tobacco, hypertension or high cholesterol – alcohol harms health relatively early in life, while
the possible protective effects on CVD occur late in life. From a public health perspective,
alcohol policies that do not focus on reducing harm can thus have serious implications, not only
on the size of the problems but also on the distribution of morbidity and mortality among age
groups (58).
Alcohol causes harm to health and societies that extends well beyond drinkers. Policies to
reduce the rates of alcohol-related harm thus not only improve the health and save the lives
of such people but can also have a broader impact on the health and well-being of families,
communities and society at large (see key points for decision-makers).
High cholesterol
Cholesterol plays an important role in a healthy body. The liver produces the amounts
needed, and foods contain cholesterol, particularly egg yolks, meat, poultry, fish, seafood and
whole-milk dairy products. Fruits, vegetables and cereals do not contain cholesterol. A high
level of cholesterol in the blood is a key component in the development of atherosclerosis,
the accumulation of fatty deposits on the inner lining of arteries. Mainly as a result of this,
cholesterol increases the risks of CVD.
In 2000, high cholesterol was estimated to cause 18% of global cerebrovascular disease
(mostly non-fatal events) and 56% of global ischaemic heart disease. Overall this amounts
to about 4.4 million deaths (7.9% of the total) and 40.4 million DALYs (2.8% of the total)
(20). Of this global burden, 18% occurred in Eur-C. In the European Region, 8.7% of DALYs
were attributable to high cholesterol levels. In most regions, the proportion of female deaths
attributable to cholesterol is slightly higher than that for men (60).
Both the population and the individual approaches are useful in lowering high cholesterol
levels.
M A J O R P R E V E N TA B L E R I S K FA C T O R S
Evidence-based assessment of key points for decision-makers: alcohol
The most effective way to tackle
alcohol-related problems in the
population is to implement multiple
policies that increase alcohol prices,
reduce the availability of alcohol
and take measures against drink–
driving and underage drinking.
Prices
Substantial evidence shows that raising
alcohol prices reduces consumption
and the level of alcohol-related
problems. In most countries and
particularly those with low alcohol
tax rates, tax-induced price increases
on alcoholic beverages lead to
increases in the state’s tax revenues
and decreases in its expenses on
alcohol-related harm. The effects
of price increases, like the effects
of other alcohol control measures,
differ among countries, depending
on such factors as the prevailing
alcohol culture and public support for
stricter alcohol controls. The effects on
alcohol-related harm are definite and
the costs low, however, making price
increases a cost-effective measure.
Availability
Stricter controls on the availability
of alcohol – especially the setting of
a minimum legal purchasing age,
a government monopoly of retail
sales, restrictions on sales times and
regulation of the number of distribution
outlets – are effective interventions.
Drink–driving
Most measures against drink–driving
– such as sobriety check-points, random
breath testing, lower limits on blood
alcohol concentrations, suspension
of driver’s licences, graduated
licensing for novice drivers and brief
interventions for hazardous drinkers
– also receive high effectiveness ratings.
These interventions are applicable
in most countries and are relatively
inexpensive to implement and sustain.
Underage drinking
If young people’s drinking is seen as
a specific alcohol policy problem,
increasing the legal age limit for
purchasing or selling alcoholic
beverages is the most immediate and
effective measure. Various educational
approaches have been developed to
reduce alcohol consumption. Although
they are growing in popularity, there
is little evidence of their effectiveness.
Similarly, current research findings
show that both alcohol advertising
and bans on such advertising have
only limited effects on consumption.
Source: Health Evidence Network (59).
The population-wide approach seeks to lower average levels of blood cholesterol by
encouraging people to reduce their intake of saturated fat and cholesterol, increase their
physical activity and control their weight. Health education, through the broadcast and
print media, is expected to lead to a 2% reduction in total cholesterol levels across the board.
Population strategies to reduce cholesterol are very cost-effective. Their total impact in terms of
DALYs gained, however, is relatively small, although this conclusion is based on evidence from
studies with a relatively short follow-up period. The long-term effect over generations is likely
to be greater because overall cultural changes in dietary habits can be self reinforcing (60).
The individual approach promotes the detection, treatment and education of people whose
elevated blood cholesterol places them at significantly higher risk for CVD. The combinations
of treatment with cholesterol-lowering drugs, four annual visits to a health care provider for
evaluation and one or two annual outpatient visits for health education sessions, is proven to
be cost-effective (60). Another effective intervention is educating patients: a large systematic
review showed that counselling patients can improve their dietary behaviour, including
reductions in total and saturated fat intake and increases in fruit and vegetable intake. More
intensive counselling and counselling for higher-risk patients have in general produced larger
changes than less intensive interventions delivered to low-risk populations (60).
As in the case of other risk factors analysed in this report, a multisectoral approach is needed
to achieve sustainable changes at the population level. The process should establish working
relationships between communities and governments, involve the agriculture sector and food
industry, and encourage local initiatives focusing on schools and workplaces.
Overweight and obesity
Overweight is responsible for about 7.8% of total DALYs in the WHO European Region. It is
a risk factor for a number of conditions, including diabetes, CVD, joint diseases and cancer.
35
36
T H E E U R O P E A N H E A LT H R E P O R T 2 0 0 5
Overall, excess body mass accounts for an estimated 5% of all cancers in the EU. Obesity has
a strong negative impact on the quality of life. It costs some countries up to 7% of their total
health care budget.
The global epidemic of obesity and overweight is a major challenge to the successful
prevention of NCDs (see key points for decision-makers). In many countries in the European
Region, over half the adult population has crossed the threshold of overweight, and 20–30%
of adults are categorized as clinically obese. For example, one in five adults is obese in Finland,
Germany and the United Kingdom. The figures are even higher in the eastern half of the
Region. Trends are mostly rising, although the rates of increase vary.
Information on recent policy developments in the Region is provided in the section on
overweight and obesity in children in Part 3 (pp. 64–65).
Evidence-based assessment of key points for decision-makers: obesity
The development of obesity depends
largely on genetic factors. An
inherited predisposition to obesity
is widespread in the population. In
genetically predisposed individuals,
lifestyle factors (such as diet and
exercise) and social, behavioural,
cultural and community factors
determine whether obesity develops.
Information about the cost–
effectiveness of different methods
of combating obesity, however, is
limited. Owing to the very broad range
of outcomes of preventive methods,
their cost–effectiveness cannot
be calculated. Among treatment
methods, the costs of achieving weight
loss are relatively low for dietary
counselling, behavioural therapy,
dietary replacement formulas with
low energy content, and surgical
treatment, but considerably higher
for pharmacological treatment.
Policy considerations
Most population-based prevention
programmes that have been
scientifically assessed have not shown
any favourable effect on the prevalence
of obesity. Some programmes for
both adults and children have been
successful, however, at least in the
short term. New strategies need
to be developed and assessed to
disseminate knowledge about the
causes and risks of obesity, to change
dietary habits and to motivate people
to increase their physical activity.
Concurrently, policy interventions
at the societal level are needed to
reduce the prevalence of obesity.
The risks related to obesity can be
reduced through weight reduction,
regardless of the methods used. Even
if weight reduction is not successful,
the risks associated with obesity can be
reduced by increased physical activity,
smoking cessation and improved
control of diabetes, high blood
pressure and elevated blood lipids.
Source: Health Evidence Network (61).
Low fruit and vegetable intake
Low intake of fruits and vegetables is a major risk factor to which 4.4% of the DALYs in the
Region can be attributed. Fruits and vegetables are important components of a healthy diet
and could help prevent major diseases such as CVD and gastrointestinal cancer. Low intake is
estimated to cause around 18% of gastrointestinal cancer, about 28% of ischaemic heart disease
and 18% of stroke in Europe.
Increased fruit and vegetable intake has the potential to bring important health gains. In the
15 countries comprising the EU before May 2004 and 3 of the new EU countries, it is estimated
that increasing the currently insufficient average intake of fruits and vegetables to that of the
groups consuming the most, would prevent about 23 000 deaths each year from coronary
heart disease and major types of cancer in people under the age of 65. Diet is one of the most
important modifiable determinants of cancer risk for the great majority of the population that
does not smoke.
WHO recommends an average daily intake of 400 g fruits and vegetables (49,62,63). Since
1995, the available data show that the average daily intake in the Region has ranged from a little
above 200 g in the United Kingdom and Austria to about 500 g in Greece and Finland. The
M A J O R P R E V E N TA B L E R I S K FA C T O R S
average intake in Finland nearly tripled in a relatively short period (see success story above).
There is a general north–south gradient, with higher intake in the south.
Consumption patterns for dietary components are linked to national wealth (62,63). These
patterns change over time, and, at the level of households, may depend on access to and the
availability of foods. Rapid changes in lifestyles, resulting from industrialization, urbanization,
economic development and market globalization, are significantly affecting the nutritional
status of populations. At the global level, good evidence indicates a worrying transition in
nutrition, in which rising national wealth is accompanied by changes in diet, with increased
consumption of animal-derived products, fat and oil and reduced intake of cereal foods and
vegetables. In the European Region, countries such as Greece, Portugal and Spain show some
evidence of slowly making this transition, moving from what is called the Mediterranean diet,
rich in cereals, fruits and vegetables, towards that of northern Europe, rich in meat and dairy
products. At the same time, the populations of the CIS experience rapid changes in diet owing
to massive social and technological change, which affects food supplies.
Public health policies should therefore aim at making positive changes in the patterns of
the nutrition transition. They should promote the desire for and affordability of healthy diets
and discourage unhealthy eating habits, to improve the control of diet-related public health
problems such as CVD, cancer, obesity and non-insulin-dependent diabetes.
Evidence-based assessment of key points for decision-makers: physical inactivity
Hillsdon & Thorogood (65) reviewed
studies of strategies to promote
physical activity. They searched
computerized databases of
bibliographic references, and asked
experts for information about their
current work. The studies assessed
were randomized controlled trials
of healthy adults living in their own
homes, where exercise behaviour
was the dependent variable.
The authors found that
interventions that encourage walking
and do not require attendance at a
sports or exercise facility are most
likely to lead to sustainable increases
in overall physical activity. Brisk
walking has the greatest potential for
increasing the overall activity levels of
a sedentary population and meeting
public health recommendations.
Physical inactivity
Physical inactivity is responsible for 3.5% of the total DALYs in the WHO European Region.
Industrialization, urbanization and motorized transport have reduced physical activity. At
present, more than 60% of the global population are not sufficiently active (61). In western
Europe, more than 30% of adults are not sufficiently active and levels of physical activity are
continuing to decline (64).
The validity of the data in this area is a problem, however. Very little comparable evidence
is available across populations. Most information is collected in self-reported surveys using
different standards and questions; in addition, the populations responding to the questionnaires
have different norms and expectations for health.
Physical activity is probably one of public health’s most cost-effective tools; it:
•
•
•
reduces the risk of conditions such as CVD, non-insulin-dependent diabetes and obesity;
by improving people’s physical coordination, balance and strength, reduces the risk of
injuries and is likely to prevent, for example, falls among elderly people; and
contributes to mental well-being (see key points for decision-makers).
37
38
T H E E U R O P E A N H E A LT H R E P O R T 2 0 0 5
Along with other international and national agencies, WHO encourages people to take at
least 30 minutes of physical activity each day, defined as any body movement that results in
energy expenditure. Thus physical activity includes sports but also, for example, walking (see
success story), cycling, playing, cleaning house or climbing stairs.
SUCCESS STORY
Walking programmes for elderly people in Israel
A national programme promotes walking by elderly
people in Israel. Specific local initiatives are initiated
across the country to raise their awareness of the
importance of walking to their health and to establish
walking groups. A programme coordinator in each
city or region recruits volunteers to serve as group
leaders: people over the age of 60 years who like
to walk. These volunteers participate in training
seminars and then form and lead walking groups
for elderly people in their neighbourhoods.
In addition, the programme promotes safety for the
elderly pedestrian, one of the major groups at risk on
the roads. People aged 60 and over comprise 11% of
the total population but 40% of injured pedestrians. To
promote safe walking habits, as well as health, the Road
Safety Authority distributes to walkers hats, reflectors,
membership cards and pamphlets with safety messages.
In addition to local activities, twice a year the
steering committee organizes special sport and
walking events: regional marches on World Health
Day, 7 April, and a national day in October, which
coincides with the International Day of Older
Persons. Thousands of people attend these events,
and the number of participants grows from year to
year. In 2001, about 6000 people participated.
Source: Racioppi F et al. (64).
REFERENCES
References
1. World development indicators 2005. Washington, DC, World Bank, 2005 (http://www.
worldbank.org/data/wdi2005/; accessed 2 May 2005).
2. Human development report 2004. Cultural liberty in today’s diverse world. New York, United
Nations Development Programme, 2004 (http://hdr.undp.org/reports/global/2004/;
accessed 2 May 2005).
3. European health for all database [online database]. Copenhagen, WHO Regional Office for
Europe, 2005 (http://www.euro.who.int/hfadb; accessed 2 May 2005).
4. Hertzman C, Siddiqi A. Health and rapid economic change in the late twentieth century.
Social Science and Medicine, 2000, 51:809–819.
5. Valkonen T. Trends in differential mortality in European countries. In: Vallin J et al., eds.
Trends in mortality and differential mortality. Strasbourg, Council of Europe Publishing,
2001:185–328 (Population Studies No. 36).
6. Wilkinson R, Marmot M, eds. Social determinants of health: the solid facts, 2nd ed.
Copenhagen, WHO Regional Office for Europe, 2003 (http://www.euro.who.int/eprise/
main/who/InformationSources/Publications/Catalogue/20020808_2, accessed 27 April
2005).
7. Wall S, Persson G, Weinehall L. Public health in Sweden: facts, vision and lessons. In:
Beaglehole R, ed. Global public health: a new era. Oxford, Oxford University Press, 2003.
8. Berkman LF. Seeing the forest and the trees: new visions in social epidemiology. American
Journal of Epidemiology, 2004, 160:1–2.
9. Marmot M, Wilkinson RG. Psychosocial and material pathways in the relation between
income and health: a response to Lynch et al. BMJ, 2001, 322:1233–1236.
10. Simonato L et al. Avoidable mortality in Europe 1955–1994: a plea for prevention. Journal of
Epidemiology and Community Health, 1998, 52:624–630.
11. Treurniet HF et al. Avoidable mortality in Europe (1980–1997): a comparison of trends.
Journal of Epidemiology and Community Health, 2004, 58:290–295.
12. Andreev EM et al. The evolving pattern of avoidable mortality in Russia. International
Journal of Epidemiology, 2003, 32:437–446.
13. Andreev EM et al. Health expectancy in the Russian Federation: a new perspective on the
health divide in Europe. Bulletin of the World Health Organization, 2003, 81(11):778–787.
14. Bajekal M et al. Healthy life expectancy at health authority level. Health Statistics Quarterly,
2002, 16:25–37 (http://www.statistics.gov.uk/articles/HSQ/HealthLifeExpectancy_HSQ16.
pdf, accessed 27 April 2005).
15. Healthy life expectancy in Scotland. Executive summary. Edinburgh, Information and
Statistics Division, NHS Scotland, 2004 (http://www.isdscotland.org/isd/files/HLE%20_
exec_summary.pdf, accessed 27 April 2005).
39
40
T H E E U R O P E A N H E A LT H R E P O R T 2 0 0 5
16. Murray CJL et al. A critical examination of summary measures of population health.
Bulletin of the World Health Organization, 2000, 78(8):981–994. (http://www.who.int/
docstore/bulletin/pdf/2000/issue8/99-0102.pdf, accessed 27 April 2005).
17. Murray CJL et al., eds. Summary measures of population health: concepts, ethics,
measurement and applications. Geneva, World Health Organization, 2002 (http://
whqlibdoc.who.int/publications/2002/9241545518.pdf, accessed 27 April 2005).
18. Ezzati M et al. Comparative quantification of health risks: global and regional burden of
disease attributable to selected major risk factors. Geneva, World Health Organization, 2004.
19. The world health report 2004 – Changing history. Geneva, World Health Organization, 2004
(http://www.who.int/whr/2004/en, accessed 27 April 2005).
20. The world health report 2002 – Reducing risks, promoting healthy life. Geneva, World Health
Organization, 2002:248 (http://www.who.int/whr/2002/en, accessed 27 April 2005).
21. Ezzati et al. Estimates of global and regional potential health gains from reducing multiple
major risk factors. Lancet, 2003, 362(9380):271–280 .
22. Humanitarian assistance: mental health in the Balkans. Copenhagen, WHO Regional Office
for Europe, 2004 (http://www.euro.who.int/mentalhealth/CtryInfo/20030723_1, accessed
27 April 2005).
23. World report on road traffic injury prevention. Geneva, World Health Organization, 2004
(http://www.who.int/world-health-day/2004/infomaterials/world_report/en/, accessed 27
April 2005).
24. Racioppi F et al. Preventing road traffic injury: a public health perspective for Europe.
Copenhagen, WHO Regional Office for Europe, 2004 (http://www.euro.who.int/
document/E82659.pdf, accessed 27 April 2005).
25. Averting AIDS crises in eastern Europe and central Asia. Washington, DC, World Bank,
2003.
26. Report on the global AIDS epidemic: 4th global report. Geneva, Joint United Nations
Programme on HIV/AIDS, 2004 (UNAIDS/04.16E).
27. European Centre for the Epidemiological Monitoring of AIDS (EuroHIV). HIV/AIDS
surveillance in Europe. End-year Report 2003, No. 70. Saint Maurice, Institut de Veille
Sanitaire, 2004 (http://www.eurohiv.org, accessed 27 April 2005).
28. Hamers FF, Downs AM. The changing face of the HIV epidemic in western Europe: what
are the implications for public health policies? Lancet, 2004, 364(9428):83–94.
29. Mocroft A et al. Changes in the cause of death among HIV positive subjects across Europe:
results from the EuroSIDA study. AIDS, 2002, 16:1663–1671.
30. Hamers FF, Downs AM. HIV in central and eastern Europe. Lancet, 2003, 361(9362):1035–
1046.
31. Dehne K et al. The HIV/AIDS epidemic in eastern Europe: recent patterns and trends and
their implications for policy-making. AIDS, 1999, 13:741–749.
REFERENCES
32. Corbett EL et al. The growing burden of tuberculosis: global trends and interactions with
HIV epidemic. Archives of Internal Medicine, 2003, 163:1009–1021.
33. Progress with Roll Back Malaria in the WHO European Region. Copenhagen, WHO
Regional Office for Europe, 2000.
34. Progress with Roll Back Malaria in the WHO European Region. Copenhagen, WHO
Regional Office for Europe, 2001 (http://www.euro.who.int/document/E73499.pdf,
accessed 27 April 2005).
35. Strategy to Roll Back Malaria in the WHO European Region. Copenhagen, WHO Regional
Office for Europe, 1999 (http://www.euro.who.int/document/e67133.pdf, accessed 27 April
2005).
36. Scaling up the response to malaria in the European Region of WHO. Copenhagen, WHO
Regional Office for Europe, 2002 (WHO Regional Committee for Europe resolution EUR/
RC52/R10; (http://www.euro.who.int/Governance/resolutions/2002/20021231_3, accessed
27 April 2005).
37. Malaria vectors and approaches to their control in malaria-affected countries of the
WHO European Region. Report of the Regional Meeting on Vector Biology and Control.
Copenhagen, WHO Regional Office for Europe, 2001.
38. Global tuberculosis control. Geneva, World Health Organization, 2004 (http://www.who.
int/tb/publications/global_report/en/, accessed 27 April 2005).
39. DOTS expansion plan to stop TB in the WHO European Region 2002–2006. Copenhagen,
WHO Regional Office for Europe, 2002 (WHO/HTM/TB/2004.331; http://www.euro.who.
int/document/E77477.pdf, accessed 27 April 2005).
40. Scaling up the response to tuberculosis in the European Region of WHO. Copenhagen, WHO
Regional Office for Europe, 2002 (WHO Regional Committee for Europe resolution EUR/
RC52/R8; http://www.euro.who.int/Governance/resolutions/2002/20021231_5, accessed
27 April 2005).
41. European framework to decrease the burden of TB/HIV. Copenhagen, WHO Regional Office
for Europe, 2003 (http://www.euro.who.int/document/E81794.pdf, accessed 27 April
2005).
42. Global tuberculosis control: surveillance, planning, financing. WHO report 2005. Geneva,
World Health Organization, 2005 (http://www.who.int/tb/publications/global_report/en/,
accessed 12 May 2005).
43. Stop Tuberculosis Initiative. Geneva, World Health Organization, 2000 (World Health
Assembly resolution WHA53.1; http://policy.who.int/cgi-bin/om_isapi.dll?infobase=WHA
&softpage=Browse_Frame_Pg42, accessed 27 April 2005).
44. Successful prevention of noncommunicable diseases: 25 year experiences with North Karelia
Project in Finland. Geneva, World Health Organization, 2003 (http://www.who.int/hpr/
successful.prevention.1.shtml, accessed 27 April 2005).
41
42
T H E E U R O P E A N H E A LT H R E P O R T 2 0 0 5
45. Global strategy on diet, physical activity and health. Geneva, World Health Organization,
2004 (World Health Assembly resolution WHA57.17; http://www.who.int/gb/ebwha/pdf_
files/WHA57/A57_R17-en.pdf, accessed 2 May 2005).
46. Global Strategy on Diet, Physical Activity and Health. Geneva, World Health Organization,
2004 (http://www.who.int/gb/ebwha/pdf_files/WHA57/A57_R17-en.pdf, accessed 27
April 2005.
47. The WHO MONICA project [web site]. Helsinki, National Public Health Institute (KTL),
2005 (http://www.ktl.fi/monica, accessed 12 May 2005).
48. Tunstall-Pedoe H, ed. MONICA monograph and multimedia sourcebook. World’s largest
study of heart disease, stroke, risk factors and population trends 1979–2002. Geneva, World
Health Organization, 2003 (http://whqlibdoc.who.int/publications/2003/9241562234.pdf,
accessed 9 May 2005).
49. Mackay J et al. The atlas of heart disease and stroke. Geneva, World Health Organization,
2004 (http://whqlibdoc.who.int/publications/2004/9241562768.pdf, accessed 27 April
2005).
50. Guidelines for controlling and monitoring the tobacco epidemic. Geneva, World Health
Organization, 1998.
51. Coventry Evening Telegraph, 29 July 2004 (http://iccoventry.icnetwork.co.uk/0100news/
0100localnews/tm_objectid=14474488%26method=full%26siteid=50003-name_page.
html, accessed 27 April 2005)
52. Coventry Teaching Primary Care Trust [web site]. Coventry, National Health Service, 2005
(http://www.coventrypct.nhs.uk/; accessed 27 April 2005).
53. Health Evidence Network. Which are the most effective and cost-effective interventions for
tobacco control? Copenhagen, WHO Regional Office for Europe, 2003 (http://www.euro.
who.int/eprise/main/WHO/Progs/HEN/Syntheses/tobcontrol/20030822_1, accessed 2
May 2005).
54. WHO Framework Convention on Tobacco Control. Geneva, World Health Organization,
2005 (http://www.who.int/tobacco/framework/en/, accessed 2 May 2005).
55. Rehm J et al. Alcohol as a risk factor for global burden of disease. European Addiction
Research, 2003, 9:157–164.
56. Rehm J et al., eds. Comparative quantification of health risks: Global and regional burden of
disease due to selected major risk factors. Geneva, World Health Organization, 2004:959–
1108.
57. Global status report on alcohol 2004. Geneva, World Health Organization, 2004:48–49
(http://whqlibdoc.who.int/publications/2004/9241562722_(425KB).pdf, accessed 27 April
2005).
58. Ashley MJ et al. Beyond ischemic heart disease: are there other health benefits from
drinking alcohol? Contemporary Drug Problems, 2000, 27:735–777.
REFERENCES
59. Health Evidence Network. What are the most effective and cost-effective interventions in
alcohol control? Copenhagen, WHO Regional Office for Europe, 2004 (http://www.euro.
who.int/eprise/main/WHO/Progs/HEN/Syntheses/alcohol/20040219_3, accessed 2 May
2005).
60. Ammerman A et al. Counseling to promote a healthy diet. Rockville, MD, Agency for
Healthcare Research and Quality (AHRQ), 2002.
61. Health Evidence Network. Which are the known causes and consequences of obesity, and
how can it be prevented? Copenhagen, WHO Regional Office for Europe, 2004 (http://www.
euro.who.int/hen/syntheses/short/20040908_1, accessed 2 May 2005).
62. Robertson A et al., eds. Food and health in Europe: a new basis for action. Copenhagen,
WHO Regional Office for Europe, 2004 (WHO Regional Publications, European Series,
No. 96; http://www.euro.who.int/eprise/main/who/InformationSources/Publications/
Catalogue/20040130_8, accessed 16 December 2004).
63. Food and health in Europe: a new basis for action – Summary. Copenhagen, WHO Regional
Office for Europe, 2002 (http://www.euro.who.int/eprise/main/who/InformationSources/
Publications/Catalogue/20030224_1, accessed 16 December 2004).
64. Racioppi F et al. A physically active life through everyday transport. With a special focus on
children and older people and examples and approaches from Europe. Copenhagen, WHO
Regional Office for Europe, 2002 (http://www.who.dk/document/e75662.pdf, accessed 27
April 2005).
65. Hillsdon M, Thorogood M. A systematic review of physical activity promotion strategies.
British Journal of Sports Medicine, 1996, 30(2):84–89.
43
CHILD AND
ADOLESCENT
HEALTH AND
DEVELOPMENT
46
T H E E U R O P E A N H E A LT H R E P O R T 2 0 0 5
Rationale for the focus on children
This report uses the definition of child from the
United Nations Convention on the Rights of
the Child: “every human being below the age of
eighteen years” (1). The general term children’s
health fully includes infants, pre-school children,
older children and adolescents. These groups
also comprise subgroups that differ in stages of
development, risks to and determinants of health,
and needs for services and public health measures.
This third part of the report has a structure
similar to the general overview in Part 2. It reviews
mortality indicators, the summary measures of
the burden of disease (in DALYs) and selected
morbidity indicators. Examples of appropriate
policy responses and concrete interventions are
given. Part 3 ends with a summary of a systematic
review – coordinated by the Health Evidence
Network at the WHO Regional Office for Europe
in conjunction with the preparation of this report
– of the evidence on the factors that influence the
effective implementation of disease prevention and
health promotion programmes for children.
Health in childhood determines
health throughout life and into the
next generation. Despite overall
improvements, children’s health
in the European Region shows
large differences according to age,
gender, geographical location and
socioeconomic position, both within
and between countries. Social
inequalities are increasing in all
countries, particularly in the eastern
half of the Region.
Because working for optimal health
and development for all children
is an increasingly complex task for
countries, the WHO Regional Office
for Europe is developing a new
approach to assist them: a strategy
for child and adolescent health in
the European Region. In addition, all
countries need better information
on and monitoring systems for
children’s health, particularly in
relation to social inequalities.
Gaps in children’s health
As indicated in Part 2, most indicators show that, in recent decades, public health has succeeded
in improving health at the population level in the WHO European Region and globally, but
health inequalities within and between countries remain unacceptably large and continue to
grow (2). The evidence clearly demonstrates that social factors account for the bulk of these
disparities (3–5), and people from socially disadvantaged groups get sicker and die sooner than
people in more privileged social positions (6). Public health action to address the major causes
of the burden of disease will therefore continue to be less successful than necessary and possible,
as long as it fails also to address the root causes of morbidity and mortality.
This general conclusion holds true for children’s health, too. For example, rates of mortality
and malnutrition in children continue to decline globally, but large inequalities between poor
and better-off children continue to exist, both between and within countries. These inequalities
appear to be widening. WHO therefore concluded that the health of children and mothers
must be reinstated as an important item in the agendas of health and education ministries, and
United Nations and other organizations (7,8).
Broader, better targeted interventions
In many areas, what to do – for example, to reduce child mortality or promote healthy behaviour
– is well known, but the effective interventions available do not reach enough people or target
R AT I O N A L E F O R T H E F O C U S O N C H I L D R E N
those in most need (9). Interventions must reach more children and mothers; their delivery
must be scaled up and high coverage rates maintained, particularly among vulnerable groups. In
the longer term, all partners in work to improve children’s health – including governments, and
international and nongovernmental organizations – must commit themselves to strengthening
the capacity for public health programmes at the local level. Most importantly, interventions
to reduce disease and save lives must take account of the social determinants of health, as these
factors determine whether available knowledge and resources reach those in need. Unfortunately,
neglect of these factors continues to undermine efforts to improve health (10).
Improving the health of young people will contribute substantially to achieving the
Millennium Development Goals (11).
1.
2.
3.
4.
5.
6.
7.
8.
Eradicate extreme poverty and hunger.
Achieve universal primary education.
Promote gender equality and empower women.
Reduce child mortality.
Improve maternal health.
Combat HIV/AIDS and other diseases.
Ensure environmental sustainability.
Develop a global partnership for development.
World leaders adopted the Goals as landmarks of what could and needed to be done, and
challenged the public health community to develop a map for their achievement. The Goals
establish poverty reduction and human development as the cornerstones for sustaining social and
economic progress (see also pp. 75–77).
The first seven Goals focus on tackling poverty in all its forms. They are designed to break the
cycle of poverty and ill health. Better health is strongly correlated with improved educational
attainment, which in turn leads to better health. Both education and health are resources for
increased income, which enables access to better education and health care, and health enhancing
environments. All the Goals are relevant to children’s health, welfare and development.
Reasons to focus on children
This report focuses on children’s health for two reasons. First, as mentioned in Part 2, fewer
children are being born in the WHO European Region and they are likely to live a long time.
Thus, it is vital to do everything possible to ensure that these children grow up healthy and
maintain their health into old age. Second, childhood is the best period in which to act. This
is when action is most effective in both promoting good health and preventing ill health in
childhood and later life.
Health in childhood determines health over the total lifespan and into the next generation. The
first years of life lay the foundations for people’s achievement of their health potential. How the
brain develops in early life determines whether people have the skills to cope with disease risk in
later life (12). Problems in early childhood development have a strong relationship to NCDs in
adult life. Health promotion is most effective in the early years of life.
Further, disease prevention and control should counter the negative influences on health as
early as possible in life, to keep problems from passing into later stages of development. To a large
extent, each stage in the development of a child prepares the way for the next. That is why it is
important to anticipate risks as and when they are likely to emerge. This means that the wisest
policies on children’s health focus on early and well-targeted interventions.
47
48
T H E E U R O P E A N H E A LT H R E P O R T 2 0 0 5
In addition to the public health rationale and the moral obligation, investment in children’s
health is good economics, as it literally pays off for the individual and society. Thus, this
investment must be society’s responsibility and extend beyond the health sector.
Children in the Region show large differences in health according to age, sex, geographical
location and socioeconomic position, both within and between countries, so general
approaches must be adapted for sustainable implementation in the very different circumstances
of children and families. As mentioned, the overall improvements in the population averages
for a range of conventional health indicators hide increasing social inequalities in all countries,
particularly in the eastern half of the Region. Even in the 15 more affluent countries comprising
the EU before May 2004, about 30–50% of all deaths and health problems that occur in children
are estimated to be associated with parents’ low socioeconomic position (13). In addition,
the social gradient is mostly steeper within countries than between them. Thus, public health
systems clearly face an increasingly complex task in ensuring the circumstances for optimal
health and development for all children.
New strategy
There is growing international agreement that a new approach is needed for this task. Following
a 2003 resolution of the WHO Regional Committee for Europe (14), the WHO Regional Office
for Europe is developing a European strategy for child and adolescent health and development
(15). Its aim is to assist Member States in formulating their own policies and programmes, not
to act as a straitjacket for the Region. The strategy identifies the main challenges to child and
adolescent health and, most important, provides options that are based on evidence and the
experience gleaned by WHO over recent years. The strategy and an associated toolkit will help
Member States identify any gaps in their plans and clarify their priorities for future investment.
Because circumstances vary, each country in the Region must decide its own priorities.
Countries will remain free to set their own targets for achievement, in the light of their
particular circumstances and resources. While the principles and approaches that underpin
child and adolescent health and development are universal, their application may vary from
country to country in this complex and diverse Region.
All these approaches share basic features: they must be evidence based, broad and better
aimed at underprivileged groups in the population (see pp. 78–81 for further discussion of
factors in success). While more effort and, naturally, resources are needed for the successful
implementation of the interventions known to be effective, one thing is clear: delays in action
on children’s health and development are not primarily a question of evidence but one of the
ambition required to pursue substantial improvements. In particular, the recent economic
growth in most eastern countries in the Region is an opportunity to scale up services for child
health and development that will pay off in the future.
The aim is to ensure full coverage of children of all social and ethnic groups by the best
achievable public health services. This must be supplemented by access to high-quality health
services, which can deliver indispensable results. This short report does not include health care
services in its scope, but aims to focus on population-level indicators of interest to public health.
The process of preparing this report uncovered many limitations in the availability of adequate
information on children’s health, as discussed below. In general, all countries need better
information on and monitoring systems for children’s health, particularly in relation to social
inequalities.
R AT I O N A L E F O R T H E F O C U S O N C H I L D R E N
Information on children’s health
In general, good data on children’s health are still surprisingly difficult to obtain. Regrettably,
existing data are often inaccurate, incomplete or inconsistent. The methods used to access and
present data vary considerably between countries, adding to the complexities of analysis. The
lack of data on the total population of children (that is, all those aged 0–17 years) is a particular
problem. A more standardized approach will not only help build the evidence base for children’s
health and development but also improve the confidence of policy-makers in the information
available to support policy.
In particular, neonatal, infant and child mortality is underreported in several countries,
mainly in the Caucasus and central Asia, which have only recently started to use the
international definition of live birth. Underreporting is also a problem in some countries in
the Balkans. Household surveys carried out in some of these countries in the 1990s produced
estimates of mortality that are much higher than the official figures, which are based on
registration. Similarly, the children’s immunization rates given by official sources are sometimes
at variance with those derived from household surveys (16).
Owing to these differences, in May 2004, WHO, the United Nations Children’s Fund
(UNICEF), the United Nations Population Division and the World Bank agreed to carry out
regular, joint activities to improve the estimation of mortality. Accordingly, WHO and UNICEF
produced a consistent set of mortality rates for children aged under 5 years by country for
the period 1990–2003; these may not be directly derived from reported data and should be
interpreted as the best estimates of WHO, rather than the official views of Member States.
WHO published these data with uncertainty intervals, to communicate the plausible range
between the high and low estimates for each country (8). Fig. 5 shows the uncertainty intervals
in relation to the officially reported data. In a number of countries in the Eur-B and -C groups,
mainly in the Caucasus and central Asia, even the low WHO estimate is considerably higher
than the official figures (see Annex Table 2 for the WHO estimates of the midpoints of the
uncertainty intervals). While the rates in Eur-A are around 5 deaths per 1000 live births, those
for some central Asian republics are estimated at over 100 per 1000.
Unfortunately, health data for socioeconomic subgroups are mainly available through
research studies or population surveys. For this reason, the country averages usually conceal
the differences between such groups, such as the health experience of subgroups with a mobile
lifestyle, including homeless people and refugees; or the impact of disability on access to
services, such as education.
Another major concern is the lack of sufficient information at the population level on the
positive aspects of children’s health and development.
The WHO Regional Office for Europe carried out a special data collection exercise
to support the move to a more child-centred approach to compiling and presenting data
on children’s health. The Regional Office sent the data specifications – based on the
recommendations of the Child Health Indicators of Life and Development (CHILD) project
(18,19) – to all 52 Member States in the Region and invited them to nominate focal points; the
focal points submitted the data available to them by September 2004. These were added to the
data already available in the Regional Office. The analyses for this report have used all data
selectively (see Annex Table 6).
The overall conclusion of the exercise is that the required data are not readily available
in a single central database in any country, and compiling them requires special effort and
resources. Thus, the existing data on children’s health are most likely underused.
49
50
Fig. 5. Official
figures and WHO
estimates of deaths
in children under 5
in the WHO
European Region,
2003
T H E E U R O P E A N H E A LT H R E P O R T 2 0 0 5
3
3
4
4
3
4
5
4
5
4
3
5
5
4
5
Iceland
Sweden
Czech Republic
Finland
Germany
Monaco
0
Norway
1
3
5
5
4
5
San Marino
Spain
Andorra
0
Austria
Belgium
Cyprus
Denmark
France
Greece
Italy
Luxembourg
Netherlands
Slovenia
Switzerland
Ireland
Israel
Malta
a
The former Yugoslav
Republic of Macedonia.
b
NA = not available.
Source: official estimates
from the European health
for all database (17); WHO
estimates from The world
health report 2005 – Make every
mother and child count (8).
4
5
5
4
5
Portugal
United Kingdom
0
5
6
6
5
6
7
5
6
5
5
6
6
5
6
5
4
6
6
5
6
6
4
6
5
4
6
6
5
6
5
3
6
6
4
6
7
5
7
6
6
7
6
5
7
7
5
7
6
5
7
10 20
7
6
8
8
7
9
9
7
9
9
7
9
9
7
10
9
7
10
10
9
11
13
11
13
12
10
15
12
13
15
14
14
16
16
16
16
16
15
20
21
19
21
13
18
22
14
19
23
13
Croatia
Estonia
Poland
Slovakia
Hungary
Lithuania
Belarus
TFYR Macedoniaa
Latvia
Serbia and Montenegro
Bulgaria
Russian Federation
Bosnia and Herzegovina
Romania
Ukraine
Albania
Armenia
18
Republic of Moldova
Turkey
Georgia
Uzbekistan
Azerbaijan
WHO estimate (low)
WHO estimate (high)
29
24
38
40
NAb
37
41
12
40
63
28
20
76
53
84
56
23
90
77
53
Turkmenistan
Tajikistan
49
24
Kyrgyzstan
Kazakhstan
Official figures
93
21
0
20
40
Deaths per 1000 live births
104
112
100
60
80
100
136
120
140
The development of this report was an interactive exercise, involving divisions and
programmes in the Regional Office, WHO headquarters, selected other organizations and
individual experts. In particular, WHO headquarters databases – the Global Burden of Disease
Database (20) and the WHO Global InfoBase (21) – have provided estimates of the burden of
disease in children for each Member State in the WHO European Region.
MA JOR C AUSES OF THE BURDEN OF DISEASE
Major causes of the burden of disease
Overview
The causes and rates of deaths and loss of health
In general, the health status of children in the 52
in children vary widely across the Region. In
countries in the WHO European Region reflects the
general, eastern countries have higher morbidity
widening east–west gap seen in adults, with health
and mortality from respiratory and infectious
worsening as one moves from Eur-A to -B and then
diseases, and injuries and poisoning. Asthma and
obesity rates are rising sharply in the western
-C. In contrast to this pattern, however, high rates of
countries, which have lower mortality. Vaccinerespiratory and infectious diseases in Eur-B mean
preventable diseases remain a worry across the
that overall child mortality is higher in this group
Region. The different patterns of child and adult
than in Eur-C. In Eur-A, mortality from such causes
health underline the need for countries to design
is already very low, which means a smaller disease
complementary health strategies for the two.
burden overall, but the disease patterns include
proportionately more NCDs, originating from
complex interactions of genetics, behaviour and the environment, such as asthma and allergies,
diabetes, obesity and neuropsychiatric disorders.
Overall, the countries in the Region have made substantial progress in reducing mortality
and morbidity from acute conditions, although considerable problems remain in many
countries in Eur-B and -C, particularly Turkey and the countries in the Caucasus and central
Asia.
Unintentional and intentional injuries remain much too frequent in all countries. In
addition, evidence is accumulating of growing inequalities in health in many countries.
This section of Part 3 begins by analysing mortality in the group aged 0–14 years, which
provides one very important view on children’s health. An analysis of the DALY estimates
for this age group follows, and provides useful additional insights. The section concludes by
examining two additional types of indicators of child health: largely preventable conditions and
very complex conditions.
Mortality in children
Death is the childhood health outcome that is most difficult to accept. The burden it places
on the family may last for many years. In addition, it is particularly sensitive to the impact of
and inequalities in both the immediate and the more distant determinants of health, including
health-related policies. This section discusses deaths in children in various age groups.
The results for overall mortality are somewhat better for Eur-C than Eur-B, which includes
many of the countries with higher child mortality. The opposite is in general true of adults, as
shown in Part 2. From a global perspective, however, Eur-B and -C have low child mortality.
In addition, the differences between the two are small in comparison to those between them
and Eur-A, where child mortality is very low. The differences in the patterns of child and adult
health underline the need for countries to design complementary health strategies for the two.
Children under 5 years
In general, deaths in both infants and children aged 1–4 years have decreased in most countries
in the European Region, although at different speeds. In particular, most of the countries in the
Caucasus and central Asia, which have very high mortality in children under 5, made very little
51
52
T H E E U R O P E A N H E A LT H R E P O R T 2 0 0 5
progress in the period 1995–2003 (8). This has contributed to the widening of the differences
between the countries in the Region.
Infants
Mortality rates for children aged under 1 year have continued to fall in the Region as whole. The
average in Eur-A is around 4.6 deaths per 1000 live births. That for Eur-B remains very high
(25.8 per 1000) and improvement actually halted in the period 1998–2002, while the average for
Eur-C improved considerably, to 11.7 per 1000 live births in 2003.
As to individual causes, perinatal conditions are responsible for 50%, 35% and 44% of infant
deaths in Eur-A, -B and -C, respectively. The mortality due to infectious and parasitic diseases
in Eur-A (8 per 100 000 children under 1 year of age), however, is only one fifteenth of the
level in Eur-B (126 per 100 000). Eur-C occupies a level between the two: 58 per 100 000. The
differentials are even larger when the rates of death due to respiratory diseases are considered.
These are around 6.6 per 100 000 in Eur-A countries, but 480 in Eur-B and 119 in Eur-C.
As mentioned, analyses of socioeconomic differentials in mortality and other indicators
of children’s health are not yet common, although both scientists and governments have
declared that social inequalities are a priority in public health. As an example that highlights
the significance of social variables, Fig. 6 shows postneonatal mortality in six CIS countries
according to the level of mothers’ education. The rates were estimated by population surveys,
and show differences in some countries of the magnitude of 1:3 or even 1:5.
Fig. 6. Postneonatal
mortality in six CIS
countries according
to the level of
mothers’ education
4
Armenia (2000)
Postsecondary education
17
24
Technical education
7
Georgia (1999)
Primary/Secondary education
12
24
17
Uzbekistan (1996)
19
24
22
Kazakhstan (1999)
26
29
29
Kyrgyzstan (1997)
20
43
Note. Figures cover
postneonatal mortality
in the 10 years preceding
the surveys.
Source: data from
Reproductive, maternal
and child health in eastern
Europe and Eurasia: a
comparative report (22).
15
Turkmenistan (2000)
30
45
0
5
10
15
20
25
30
35
40
45
50
Deaths per 1000 live births
Children aged 1–4 years
The reporting on children aged 1–4 years seems to be complete enough in the countries of the
Region with regular registration systems, that the differences in the overall mortality rates of
the country groups were not subject to doubt in this report’s analysis. As Fig. 7 shows, there is
considerable scope for improvement, particularly in Eur-B.
In this age group, mortality rates are lowest in Eur-A. The overall mortality rates in Eur-B and
-C are about six times and three times, respectively, those in Eur-A, and deaths from external
causes are about four times more frequent.
MA JOR C AUSES OF THE BURDEN OF DISEASE
All causes
27.4
Males
154.1
91.7
21.8
Females
135.7
70.8
Respiratory diseases
1.5
Males
68.9
Eur-A
11.8
53
Fig. 7.
Mortality in
children aged
1–4 years in
Eur-A, -B and
-C, by main
causes and
sex, 2003
Eur-B
1.2
Females
64.8
9.5
Eur-C
Infectious diseases
1.8
Males
16.2
6.3
1.4
Females
15.5
4.8
Congenital malformations
3.9
7.9
Males
13.9
3.5
6.1
Females
13.6
Cancer
Males
3.7
5.2
6.9
Females
2.9
4.6
5.6
External causes
7.6
Males
31.5
39.5
5.5
Females
23.1
23.5
Other diseases
2.1
Males
8.4
16.0
7.3
Females
21.6
13.8
0
50
100
Deaths per 100 000
150
Respiratory diseases are the main cause of death in Eur-B, responsible for 45% of all deaths.
In fact, the excess mortality from these diseases is mainly responsible for the higher overall
mortality in Eur-B than Eur-C. Mortality from individual causes within this group (such as
acute respiratory infections, pneumonia and influenza) shows differences across countries of
three-digit magnitude.
Deaths from infectious and parasitic diseases – which are relatively easy to prevent – are
higher in Eur-B, while deaths from congenital malformations are higher in Eur-C by a similar
rate. Cancer mortality is relatively evenly distributed across the Region.
Interventions for children under 5
Several evidence-based interventions are available and feasible for implementation in countries
with high mortality in children under 5. Analyses indicate that the consistent implementation
of a set of selected interventions at high levels of coverage could prevent about two thirds of
such deaths. WHO has combined several of these interventions to create integrated guidelines,
Source: European health
for all database (17).
54
T H E E U R O P E A N H E A LT H R E P O R T 2 0 0 5
and developed tools to facilitate their joint delivery. A core set of tools is available, and others
are being developed, to improve health workers’ skills, health system capacities, and family and
community practices. These strategies include:
•
•
•
•
integrated management of pregnancy and childbirth (23), including antenatal care, skilled
attendance at birth, postpartum care and support for appropriate home-care practices;
Integrated Management of Childhood Illness (IMCI) (24), including case management of
children aged 0–4 years and support for appropriate home-care practices;
Expanded Programme on Immunization (25); and
the Global Strategy for Infant and Young Child Feeding (26).
In partnership with UNICEF, the WHO Regional Office for Europe launched the IMCI
strategy in the European Region in 1997 (24). The strategy combines improved management
of childhood illness with components from nutrition, immunization and other sectors that
influence child health. IMCI’s objectives are to reduce deaths, to reduce the frequency and
severity of illness and disability, and to contribute to improved growth and development. The
core interventions comprise the integrated management of the five major causes of childhood
death: acute respiratory infections, diarrhoea, measles, malaria and malnutrition.
Integrated management includes a range of preventive and curative interventions to improve
practice both in health facilities and at home. The combination of interventions is adapted
in individual countries to accommodate local conditions and epidemiological and other
important issues.
Children aged 5–14 years
Mortality in older children is less frequently discussed, but the analysis is essential for a better
understanding of the health of children in these developmental stages and overall. As Fig. 8
shows, overall mortality rates for this age group in Eur-B and -C are 2.6 times and 3 times,
respectively, those in Eur-A. Eur-B shows extremely high mortality from infectious and
respiratory diseases, on top of the very high rates for external causes, while Eur-C is plagued
primarily by mortality from external causes and by the category other diseases and disorders.
External causes of death comprise the most important group of causes throughout the
Region, but particularly in Eur-C, where they are responsible for over 50% of all deaths. The rates
in Eur-B and -C are 2.6 times and 4.6 times, respectively, those in Eur-A. The excess mortality
from external causes of injuries and poisoning is mainly responsible for the higher overall
mortality in Eur-C than Eur-B. This situation is due largely to the extremely high rate in the
Russian Federation and its relatively large population (see p. 70 for evidence on interventions to
reduce injuries). Mortality from nearly all other causes of death is lower in Eur-C than Eur-B.
CVD emerge as a significant cause of death in this age group, while congenital malformations
retreat behind the scenes. Also relatively less important are infectious and parasitic diseases,
and respiratory diseases. Nevertheless, mortality from infectious diseases in Eur-B and -C is
6 times and 2.4 times, respectively, that in Eur-A, and mortality from respiratory diseases in
Eur-B and -C is 10 times and 3 times, respectively, the rate in Eur-A. Cancer mortality remains
relatively evenly spread across the country groups.
Overall mortality in the group aged 0–14 years
Table 14 summarizes the age-specific variations in children’s mortality discussed above. All
cause mortality in Eur-B and -C is about 3.4 times and 2.8 times, respectively, that in Eur-A.
MA JOR C AUSES OF THE BURDEN OF DISEASE
All causes
15.6
Males
41.3
48.2
11.3
Females
28.5
29.4
55
Fig. 8. Mortality
in children aged
5–14 years in
Eur-A, -B and -C,
by main causes
and sex, 2003
Digestive diseases
Males
0.2
1.1
0.4
Females
0.2
0.8
0.3
Eur-A
Eur-B
Eur-C
Infectious diseases
0.4
Males
2.6
0.9
0.4
Females
2.2
0.9
Respiratory diseases
0.6
Males
5.7
1.9
0.5
Females
4.7
1.5
CVD
0.8
2.1
1.2
Males
0.7
1.7
0.9
Females
Cancer
3.2
4.5
4.6
Males
2.5
3.6
3.8
Females
External causes
6.0
Males
16.7
29.4
3.5
Females
8.3
14.3
Other diseases
4.4
Males
8.6
9.8
3.5
Females
7.2
7.7
0
10
20
30
40
50
Deaths per 100 000
Source: European health
for all database (17).
Diseases of the respiratory system are the main killer of children aged 0–14 years in the Region
as a whole, and particularly in Eur-B, where the rate is 47 times that in Eur-A. While deaths
from respiratory diseases have been halved in the last two decades in each of the three country
groups, this cause remains the top priority in Eur-B. Clearly, the risk factors associated with
the diseases of the respiratory system remain a very important reason for the differences in
children’s mortality across the Region.
After respiratory diseases, congenital anomalies still cause very high mortality in most
countries, particularly in Eur-C, although occurring mostly in children under 5. Mortality from
this cause is difficult to compare and interpret because of differences in reporting, as well as
56
Table 14.
Mortality in
children aged
0–14 years in the
WHO European
Region, by main
causes of death,
2003
Source: European health
for all database (17).
T H E E U R O P E A N H E A LT H R E P O R T 2 0 0 5
the effects of differences in screening
procedures, specialized treatment
and national policies on children with
All causes
49.4 169.7 136.1 102.4
12.6 17.9
56.1
Respiratory diseases
1.2
malformations.
27.2 17.0
17.6
Congenital malformations
10.8
At a short distance follow external
5.9
6.4
14.8
Infectious and parasitic diseases
1.3
3.9
5.0
4.3
Cancer
3.0
causes of injury and poisoning. The
2.2
2.0
4.1
CVD
1.4
rates in Eur-C are five times those in
28.7 15.1
18.4
External causes
5.8
Eur-A. The slightly lower rates in Eur54.2 40.4
54.4
Other diseases
25.9
B than in Eur-C may be partly due to
lower numbers of motorized vehicles per head, but the overall social environment probably
plays the leading role, as indicated in the section on injuries and violence in Part 2 (pp. 23–25).
Unfortunately, there is little information on the occurrence of the factors contributing to the
high incidence and lethality of injuries.
Although the group aged 15–19 years is not analysed here, death rates from injuries and
poisoning in older teenagers are 3–5 times those the group aged 10–14 years in most countries
(Fig. 9). In addition, levels in individual countries vary widely; for example, the rates in the
middle 80% of countries ranged between 18 and 65 per 100 000 around 2002.
Further, mortality in children aged 0–14 from infectious and parasitic diseases – which
probably reflects general living conditions more directly than any other cause of death
– remains high in Eur-B and -C. In particular, the average for Eur-B is 10 times that for Eur-A.
Again, the vast majority of these excess deaths should be preventable.
As a cause of mortality in children, cancer shows relatively smaller differences across
the Region. These are difficult to interpret, due to the low numbers of deaths, and the likely
differences in reporting and incidence. Nevertheless, detailed analysis of routinely reported
mortality may provide clues to the availability of and access to medical treatment using higher
technology. A recent major study, based on high-quality data from 63 European populationbased cancer registers, found that the overall incidence of cancer in children has increased over
the last three decades, but survival has improved dramatically, although more in the west than
the east (28). In the 1990s, the overall five-year survival rate for children was 64% in eastern
countries and 75% in western ones, with east–west differences for virtually all tumour groups.
In summary, the higher average mortality in Eur-B than Eur-C is mainly due to acute
respiratory and infectious diseases, which more than compensate for the relatively lower rates
from congenital malformations and injuries. As mentioned, the differences between the two
lose importance when the very low mortality in Eur-A from practically all causes is used as a
benchmark.
Causes
Deaths per 100 000
Eur-A
Eur-B
Eur-C
Region
Children’s loss of healthy years of life (DALYs)
Annex Table 7 presents the DALY estimates for the group aged 0–14 years. For the first time,
the Global Burden of Disease project (20) has made the data available on a country-by-country
basis. These data should be interpreted with caution, however,1 particularly in relation to their
comparability between countries. At this stage, the available DALY estimates should be used
mainly to complement the understanding of the size and proportions of the overall disease
1
The DALY summary tables for the countries in the WHO European Region are for 2002, with some revisions in December 2004, to adjust for the
UNAIDS updates of HIV estimates in eastern European countries in that year. While based on the best information currently available to WHO,
the DALY estimates in general have more uncertainty at the country level than the Region level, and in some cases could be improved with
additional work and input of data on countries.
MA JOR C AUSES OF THE BURDEN OF DISEASE
Russian Federation
69.82
13.88
Estonia
69.78
10.99
Kazakhstan
65.21
25.87
Latvia
62.43
14.47
Belarus
61.31
17.12
Ukraine
54.56
19.34
Iceland
52.55
4.49
Luxembourg
47.95
14.71
Greece
42.38
6.85
Turkmenistan
40.97
20.1
Slovenia
4.33
Austria
4.99
36.62
36.05
Poland
35.79
10.58
Republic of Moldova
35.53
22.73
Ireland
35.27
7.57
Czech Republic
34.5
6.4
Finland
34.34
5.52
Croatia
34.31
4.52
France
33.57
7.6
Portugal
33.38
10.02
Albania
31.83
15.99
Norway
31.45
3.02
Kyrgyzstan
31.35
17.23
Denmark
30.86
4.94
Slovakia
29.34
10.62
Romania
28.79
18.17
Germany
28.01
5.13
Spain
27.62
5.29
Uzbekistan
26.97
14.35
Switzerland
5.19
Italy
5.03
Bulgaria
26.61
26.32
24.44
12.02
Hungary
24
8.75
Armenia
22.81
5.27
Netherlands
22.5
4.02
Sweden
20.82
4.02
United Kingdom
20.36
3.87
Israel
19.41
7.57
TFYR Macedoniaa
8.56
Malta
5.84
0
15.01
13.9
0
Georgia
Group aged 10–14 years
16.14
7.53
Tajikistan
Group aged 15–19 years
18.52
9.26
Azerbaijan
Fig. 9. Deaths from
injuries and poisoning
in two groups of
young people in most
countries in the WHO
European Region, 2002
or latest available year
99.7
27.89
Lithuania
11.3
20
40
60
Deaths per 100 000
80
100
57
a
The former Yugoslav
Republic of Macedonia.
Source: WHO mortality
database (27).
58
T H E E U R O P E A N H E A LT H R E P O R T 2 0 0 5
burden in children, and possibly to qualify some conclusions about priority needs and levels
of achievement on the basis of indicators of mortality and the occurrence of specific diseases.
From this perspective, the following broad picture has emerged from the analysis of the data.
Overall, neonatal morbidity accounts for the largest share of the disease burden on children
in the European Region. In this report, it includes low birth weight, birth asphyxia and birth
trauma, which are largely preventable. The rates of DALYs per 1000 children aged 0–14 years
range between 1.5 in Sweden and 41.6 in Kyrgyzstan. While countries have achieved very large
reductions in neonatal morbidity, considerable further improvements can be made at relatively
low cost. The large variations within the Region and the country groups emphasize the role of
efficient health and social systems.
Respiratory infections are the second-largest overall cause in terms of DALYs, but they
appear among the top 10 causes in only 20 of the 52 countries in the Region. Among these 20,
their burden in DALYs ranges from 1.5 per 1000 children in Bosnia and Herzegovina, Slovakia
and Ukraine to 59.1 per 1000 in Turkmenistan.
Congenital anomalies are among the leading 10 causes of the disease burden in every country
in the Region, and the third most important in the Region as a whole. The estimated burdens
at country level vary between 1.7 and 14.1 DALYs per 1000 children. Some of the limitations of
the data on congenital anomalies have been mentioned. In general, however, evidence points to
multiple reasons for the relatively high and persisting burden. These include increasing average
maternal age, uneven progress with primary prevention (for example, encouraging pregnant
women to take folic acid supplements and increasing prenatal screening programmes, which
should respond effectively to cultural differences), and unmet needs for counselling and a
choice of preventive interventions. In addition, the socioeconomic differentials seem to have
increased because the lower socioeconomic groups of the population have less knowledge of
the available preventive measures or lack the means to take full advantage of them. Even the
countries in Eur-A do not take full advantage of the benefits of folic-acid supplementation.
Neuropsychiatric disorders are among the 10 leading causes of the disease burden on
children in all countries and the Region as whole. In this report, these disorders include
unipolar depressive disorders, schizophrenia and migraine. The other major causes of the
disease burden on the Region’s children are iodine deficiency, unintentional injuries and
asthma. The first and third of these are discussed below.
The DALY profiles vary considerably across country groups. In summary, the data presented
in Annex Table 7 indicate the following.
1. The total burden of disease on the group aged 0–14 years varies across countries by a factor
of about 6. At the country level, the burden is highest in Tajikistan (224 DALYs per 1000
children) and lowest in Sweden (36 DALYs per 1000 children).
2. Neuropsychiatric disorders are the leading cause of the disease burden in Eur-A, but rank
lower in Eur-B and -C. Further, the differences between countries in terms of DALYs due
to these conditions are relatively small, in contrast to the variations in the shares of the
burden due to infectious diseases and other acute conditions. As acute conditions become
well controlled in central Asian and some other countries, the relative importance of
neuropsychiatric problems will increase there and in the Region as a whole.
3. The situation with congenital anomalies is similar. These are among the leading 10 causes
in all countries, but the burden is smaller in the western and central countries in the Region
than in the rest.
MA JOR C AUSES OF THE BURDEN OF DISEASE
4. Neonatal morbidity is a major problem in all countries, although its share of the disease
burden varies widely.
5. Asthma is among the leading 10 causes in all countries in Eur-A, but in only about half of the
countries in Eur-B and -C.
6. Unintentional injuries are among the leading 10 causes of the burden of disease on children
in nearly all countries in the Region.
Other indicators of child health
The mortality and DALY analyses of the overall burden of disease summarize the most salient
features of the situation and trends in children’s health, but these measures overlook or only
partially reflect some aspects and processes of health development in the Region. Owing to
their nature, clinical manifestation or the limitations of regular health monitoring, certain
conditions require a special focus and special indicators; these indicators would include, for
example, body mass index (BMI, to evaluate weight for height) and the prevalence of asthma
symptoms, rather than addressing mortality or incidence. This section points out two types of
such conditions.
The first type comprises largely preventable conditions that are or should be well under
control, provided that the recommended preventive programmes work well. The examples
addressed here are: vaccine-preventable diseases, TB and micronutrient deficiencies. The
second type comprises complex conditions that may be less well understood and are deeply
rooted in social and environmental change. Some of these take the form of creeping epidemics,
but can nevertheless be managed to a large extent by means of early prevention, diagnosis and
treatment. The examples discussed here are mental health problems, asthma and obesity.
Both types of conditions are presented using a few examples, and were not selected on the
basis of a comprehensive review. While several available good indicators of child health could
not be included, such as diabetes, a comprehensive cross-national review of all relevant data
sources and indicators would be very difficult, as the number of currently feasible indicators for
international comparisons is very small. For many indicators, experience shows serious gaps in
the available database and points to the need for better data in most countries. This is one of the
main preconditions for better public health services for all children and families.
Largely preventable conditions
Vaccine-preventable diseases
Immunization saves millions of lives every year by preventing death and disability from
infectious diseases at a fraction of the cost of treatment. Every child has the right to be protected
against vaccine-preventable diseases through a strong and effective immunization system.
Immunization is not just an effective tool to prevent death and disease among children: its
benefits last through adolescence and adulthood.
With stable, high vaccination coverage, disease declines, as shown in the European Region
by its historic certification as poliomyelitis free in 2002 and the dramatic reduction in reported
measles cases from 200 000 in 1994 to 30 000 in 2003. There are many challenges to ensuring
strong immunization services, however, both in countries undergoing health care reform and
in those with stable and well-funded primary health care systems. In the absence of disease,
immunization loses priority. Owing to insufficient vaccination coverage, outbreaks of serious
diseases such as measles continue to occur in the Region, causing unnecessary illness and death.
In addition, increasing numbers of women are reaching child-bearing age without immunity to
59
60
T H E E U R O P E A N H E A LT H R E P O R T 2 0 0 5
rubella, which increases the risk of children’s being born with congenital abnormalities. This is a
result of inadequate uptake of measles-mumps-rubella vaccine during childhood.
In addition, immunization helps reduce health inequalities, particularly in high-risk
and vulnerable populations. In all countries of the Region, some children remain at risk of
contracting preventable diseases because they do not have access to good immunization
services. The reasons for this may be socioeconomic, geographical or simply caregivers’
ignorance of the importance of timely immunization and the risks of non-immunization.
Population immunity and disease reduction can be ensured by maintaining key components
of immunization systems, such as:
•
•
•
•
the political commitment to ensure sustainable resources for high-quality vaccines;
an efficient maintenance and distribution system for vaccines, including outreach services;
the provision of appropriate information and training for health care providers and the
general public; and
an effective system of monitoring and data analysis to drive the management of evidencebased national immunization programmes.
TB
TB is an underestimated cause of morbidity and mortality in children aged 0–14 years. The
epidemiology of childhood TB varies considerably between countries. Worldwide, the share
of all TB cases occurring in children is estimated to be in the range of 2–7% in industrialized
western countries and 15–40% in lower-income countries. In the WHO European Region, the
figure most probably varies between 2% and 10%: for example, 4.2% in the Russian Federation
and 8.4% in Latvia.
Increasing rates of childhood TB have been reported from many countries in the Region,
including Austria, Israel, Denmark, Latvia, Sweden, the Russian Federation and the United
Kingdom (29). Increases are likely in countries where adult TB is rising, as deterioration in the
control of the disease rapidly affects the youngest groups.
Socioeconomic risk factors, including poverty and crowding, continue to be associated with
a greater risk of children’s developing TB. Risk factors in the Region also include immigration,
particularly in western countries, where TB has been increasingly confined to high-risk groups,
including ethnic minorities. Studies from low- and middle-income countries have confirmed
associations with poverty and malnutrition as risk factors.
Infected children make up the reservoir of future disease, so interventions specifically
targeting children can contribute considerably to reducing the future burden of TB.
Unfortunately, policy documents on TB control rarely touch on childhood TB as a public health
problem (30). This may be a side-effect of the fact that confirmation of a diagnosis of TB in
a child by sputum microscopy is rarely possible. Nevertheless, although cheap and effective
treatment of TB in children is available, it is likely not to reach many who need it, particularly
among the most socially disadvantaged.
As long as both TB and migration remain high globally, the WHO European Region can be
expected to continue to experience a steady or even increasing burden of TB in children. In
general, a weak public health infrastructure would result in such an increase. In several CIS
countries, however, two additional aggravating factors should be kept in mind: the HIV/AIDS
epidemic, which is superimposed on the TB burden, and the extraordinarily large numbers of
abandoned, homeless or neglected children.
MA JOR C AUSES OF THE BURDEN OF DISEASE
Iron deficiency
Iron deficiency is responsible for 0.7% of DALYs in the European Region. It can result in
impaired brain development in infants, and attention deficit and reduced cognitive functioning
in both children and adults. Poor feeding practices, including low breastfeeding rates, are a
major cause of iron deficiency in infants and young children in the Region. Prematurity and
infestation with parasites or helminths, as a result of poor hygiene and sanitation, also contribute
to the problem.
Iron deficiency is a major cause of anaemia. A high prevalence of mild and moderate (but
not severe) anaemia has been reported in children in Bosnia and Herzegovina, the central
Asian republics and parts of western Europe. In addition, adolescents may be prone to iron
deficiency. Significant socioeconomic deprivation can in part explain these high rates, although
probably not in all countries. UNICEF and WHO (31) reviewed iron deficiency in central Asian
countries, and recommended an integrated approach, including:
•
•
•
•
•
•
improving feeding practices for infants and young children (exclusive breastfeeding for six
months and timely introduction of appropriate iron-rich foods, such as puréed fruit and
vegetables and liquidized liver);
promoting positive dietary change in women;
fortifying cereals (such as flour) and infants’ food with iron and other micronutrients;
using oral iron supplementation;
better controlling infections; and
monitoring of programme implementation.
These interventions should be linked to public health programmes for, for example, family
planning, breastfeeding promotion, improved maternal health, Making Pregnancy Safer (32)
and IMCI (24). Governments should make firm commitments to build sustainable programmes
to prevent iron deficiency. Action should involve all stakeholders, including the food-processing
industry, the education sector, civil-society organizations and the mass media.
Iodine deficiency
Iodine deficiency remains a public health problem in much of the WHO European Region. It is
the main cause of preventable mental retardation and brain damage, decreases child survival,
causes goitre, and impairs growth and development. Iodine deficiency in pregnant women
causes miscarriages, stillbirths and other complications. Children with iodine deficiency
disorder (IDD) can grow up stunted, apathetic, mentally retarded, and incapable of normal
movements, speech or hearing (33). In the European Region, 60% of children aged 6–12 years
and 57% of the general population have insufficient iodine intake, reflected by median urinary
iodine levels below 100 μg/litre. Iodine deficiency is considered to be a public health problem in
such populations (34).
Using iodized salt to eliminate IDD has consistently been shown to be a highly cost-effective
intervention. The proportion of households using this salt is negatively correlated with the
prevalence of low iodine intake. Among WHO regions, the Americas has the highest proportion
of households consuming iodized salt (90%) and the lowest proportion of the population with
insufficient iodine intake and the European Region has the lowest household consumption of
iodized salt (27%) and the highest proportion of the population with insufficient iodine intake.
The world has made substantial progress towards eliminating iodine deficiency in the last
decade. Improved iodine intake reflects the validity of WHO’s strategy (based on salt iodization,
61
62
T H E E U R O P E A N H E A LT H R E P O R T 2 0 0 5
complemented by iodine supplementation in remote areas or severely deficient population
groups) and countries’ effective implementation of IDD control programmes. For example,
Turkmenistan achieved universal salt iodization in November 2004 and was awarded a
certificate by UNICEF and WHO. Every effort needs to be made to ensure that programmes
continue to cover at-risk populations in order to eliminate IDD.
Three complex conditions
Mental health problems, self-harm and suicide
Studies in the United Kingdom indicate that about 10% of children aged 5–15 have a mental
health disorder (35). Of these, 5% have conduct disorders, 4% emotional disorders and 1%
hyperactivity disorders. Suicide rates among people under 20 years of age have increased
in many countries over the last two decades, more clearly among males than females and
particularly in several countries in Eur-A. Owing to underregistration, however, true rates of
suicide are difficult to establish.
There is evidence that screening in mothers who have just delivered their babies identifies
postnatal depression and that subsequent home visiting improves the outcome. Some evidence
also exists for the efficacy of programmes training parents to tackle conduct disorder in their
children (36).
Many widely used suicide prevention programmes have never been scientifically assessed,
thus making it uncertain which are effective (37). In the general school population, schoolbased suicide prevention programmes that focus on behavioural change and coping strategies
are associated with a lower rate of suicide attempts and improved personality development and
coping skills. In students at high risk, school-based programmes based on skills training and
social support are effective in reducing risk factors and enhancing protective factors. No single
intervention, however, appears to be effective in reducing the suicide rate. Effective prevention
strategies need to employ a broad array of interventions addressing different risk factors at
different levels.
Given young people’s vulnerability and needs, activities to promote their mental health and
to prevent and care for mental health problems should have high priority. Many countries have
inadequate capacity in this area, however, and services and staff are often poorly prepared to
deal with developmental and age-related problems.
Because mental disorders in childhood can be important precursors of those in adults,
supporting children’s mental health should be seen as a strategic investment with many longterm benefits for individuals, health systems and societies. Thus, the 2005 WHO Mental Health
Action Plan for Europe (35) calls on Member States to take the following action:
•
•
•
•
ensuring that policies on mental health include as priorities children’s mental health and
well-being;
incorporating the rights of children specified in international treaties and conventions (1)
into mental health legislation;
involving young people as much as possible in setting priorities for activities to promote
mental health and to prevent and care for mental health problems; and
paying special attention to marginalized groups, including children from migrant families.
Mental health problems in adolescents are closely related to other health problems, including
drug and alcohol use. Understanding the prevalence of mental health problems in different
groups can help target interventions: for example, aiming preventive measures at those at high
MA JOR C AUSES OF THE BURDEN OF DISEASE
risk of suicide, especially those suffering from conduct disorder, schizophrenia, major affective
disorder, drug and alcohol use, and anorexia nervosa (39). Current research indicates that early
assessment and treatment of even the more serious and enduring mental heath disorders can
reduce the burden of some related conditions later in life (40).
Asthma
Over the last three decades, the prevalence of allergic diseases and asthma has risen throughout
the European Region. They make an important contribution to the burden of disease.
Prevalence varies widely, however, with rates of asthma symptoms in western countries being
10 times those in eastern countries. An unknown proportion of the difference is likely to be
attributable to environmental factors (41). A recent global summary (42) published prevalence
estimates in children aged 13–14 years for 30 countries in the Region, which range from under
5% in countries such as Albania, Georgia, Greece, Romania and the Russian Federation to over
30% in the United Kingdom.
Allergies and asthma are multifactorial; they result from complex interactions of genes
and the environment (40). Exposure to indoor air pollutants (such as smoke from solid-fuel
combustion) can increase the severity or frequency of asthmatic symptoms and the risk of
respiratory illness, and is associated with decreases in lung functioning. Environmental tobacco
smoke is known to increase the risk of asthma and respiratory infections, and to impair lung
functioning. In addition, outdoor air pollution (with, for example, ozone and particulate
matter) was shown to increase the risk of asthma attacks and to have an adverse impact on
respiratory health.
Factors related to a westernized lifestyle (such as less exposure to infections, siblings or
certain nutrients) may cause deficits of specific influences on the developing immune system
that lead to suboptimal immune responses and thus increase children’s risk of developing
atopic diseases. The influence of many environmental factors on the natural history of asthma
and allergies is not well understood, however, and this makes it difficult to select preventive
measures.
To reduce the prevalence and severity of asthma and allergic conditions in childhood, the
following measures are currently advocated to prevent sensitization, particularly of infants at
risk of developing allergic diseases (those with a strong family history of atopy) (41):
•
•
•
•
•
•
avoidance of exposure to environmental tobacco smoke before and after birth;
exclusive breastfeeding for 4–6 months (see also pp. 67–68), combined with avoidance of
solid foods (43);
promotion of a healthy indoor environment, including the design and construction of wellventilated, low-allergen housing;
measures to prevent indoor air pollution;
avoidance of allergens such as animal dander, house dust mites and moulds (44), substances
that cause irritation on contact with the skin and metals used in ear-piercing, etc.; and
measures to control or prevent exposure to outdoor air pollution.
Secondary prevention in children who have asthma should include education on how to
avoid environmental factors that can trigger attacks and symptoms. Worldwide, it has been
estimated that better education about the potentially fatal risks of allergy (anaphylaxis) and
asthma, especially in children, and increased dialogue between families and physician could
prevent about 25 000 childhood deaths from asthma each year (45).
63
64
T H E E U R O P E A N H E A LT H R E P O R T 2 0 0 5
A substantial reduction in exposure to air pollution from traffic (46,47) and other indoor
and outdoor sources would benefit children’s respiratory health in the long term. This could be
achieved through such measures as:
•
•
•
•
making technical improvements in vehicles and fuels;
regulating transport at the local level;
preventing indoor air pollution from, for example, solid-fuel combustion; and
preventing children’s exposure to environmental tobacco smoke.
Although extensive epidemiological and clinical evidence backs several of these
recommendations, the benefits of their implementation are, for the most part, not yet fully
evaluated. Operational research is required to investigate the impact of measures to reduce air
pollution on children’s respiratory health, including a systematic approach addressing social
deprivation and the risk of multiple exposures to, for example, traffic and tobacco smoke (48).
Overweight and obesity
Excess body weight (overweight including obesity, as determined by BMI equivalents
appropriate for children) is the most common childhood disorder in the European Region, and
is rapidly becoming a major concern globally (49). In several countries of western Europe, its
prevalence rose from around 10% in the early 1980s to around 20% by the end of the 1990s. In
several areas in southern Europe, one child in three is overweight. In general, lower rates are
found in central and eastern European countries, in part related to the economic difficulties
of the 1990s. Overweight is more prevalent among children of higher-income families in less
industrialized countries, especially as they move to urban areas, and among lower-income
families in more industrialized societies.
Overweight in children increases the risk of NCDs and leads to low self-esteem, depression
and social exclusion. Childhood obesity is associated with a number of conditions – such as
poor glucose tolerance and increased risk of non-insulin-dependent diabetes, hypertension and
sleep apnoea – but the greatest problems are increased rates of NCDs in adulthood – such as
CVD, diabetes, certain types of cancer, osteoarthritis, and gall bladder and endocrine disorders.
Obesity imposes a major financial burden on health care services. Obesity-related disorders
account for up to 7% of direct health care costs in the western half of the Region and 5% in
eastern countries (50,51).
Prevention is the only feasible option and is essential for all countries. WHO (49,52)
recommends the development of multisectoral strategies for supportive action to increase the
availability of appropriate foods, reduce dependence on motorized transport, increase access to
recreation facilities and ensure that health information is easily understood, relevant, consistent
and widely available (see recent developments in policy, and pp. 72–73). Interventions in
schools need to go hand in hand with changes in the social and cultural context. Health and
education systems, parents, the food industry, the mass media, urban planners and politicians
at all levels will need to coordinate their efforts.
A systematic review of 10 trials (57) designed to prevent obesity in childhood assessed
the effectiveness of educational, health promotion and/or psychological, family, behavioural
therapy, counselling and management interventions focused on diet, physical activity and/or
lifestyle and social support. High-quality data were limited, and no generalizable conclusions
could be drawn, although concentration on strategies that encourage reduced sedentary
behaviour and increased physical activity might be fruitful. Nevertheless, studies suggest that
MA JOR C AUSES OF THE BURDEN OF DISEASE
Recent developments in policy in countries
Food and nutrition policies can protect and promote
health and reduce the burden of disease related to
inappropriate diet, while contributing to socioeconomic
development and a sustainable environment (46).
Different sectors play complementary roles in formulating
and implementing such policies. These usually include
strategies on food, nutrition and a sustainable food supply
(food security). The European Region offers some good
recent examples of policies on food and nutrition.
The Netherlands
Although life expectancy is increasing in the
Netherlands, unhealthy lifestyles are affecting it.
Obesity leading to disease is one of the major issues
that the country emphasizes in its health policy (53).
Slovenia
To improve dietary habits and reduce the harm
caused by diseases related to unhealthy nutrition
and lifestyles, Slovenia launched a national nutrition
policy programme in March 2005 (54).
Spain
Changes in eating habits and lifestyles are the principal
causes of the increase in obesity in Spain. The country
has adopted a strategy on nutrition, physical activity
and the prevention of obesity (55) that recognizes the
multifactorial nature of obesity, aims to improve the diets
of and encourage regular physical activity by all citizens,
and pays special attention to prevention in childhood.
United Kingdom
A government white paper on public health
(56) lists new measures including:
• curbs on the promotion of unhealthy foods to children;
• clear, unambiguous labelling of the nutritional
content of food;
• advice from National Health Service health trainers to
individuals on how to improve their lifestyles; and
• a wide range of measures to tackle social and
geographical inequalities in health.
most children are at risk of weight gain and that preventive strategies taking a population
approach will benefit the health of all children.
Recognizing that obesity is a major public health threat, the WHO Regional Office for
Europe has designated it a priority area for work in the coming years. A planned ministerial
conference late in 2006 will aim to raise both awareness of the problem in the Region and
political commitment to counteracting it.
65
66
T H E E U R O P E A N H E A LT H R E P O R T 2 0 0 5
Children’s health determinants and
policy responses
Poverty is the greatest threat to children’s health,
regardless of a country’s level of development
(58). This section discusses the range of health
determinants, including some interventions found
to be effective (see also Annex Table 6). The next
section (pp. 78–81) draws together the various
factors mentioned here, to list those shared by
successful interventions.
Determinants in early stages
of development
Poverty is the greatest threat to
children’s health, regardless of a
country’s level of development.
Rates of disease and health
threatening behaviour are closely
linked to socioeconomic factors,
which include poor neonatal health
(from malnutrition, for example),
lack of access to health care,
unhealthy or unsafe environments,
and behavioural factors such as early
smoking, drinking or drug taking.
Links to maternal health
Children’s health has a close link with policies on
maternal health. The mother’s living circumstances fundamentally influence the health of the
child. Further, initial work to protect and promote children’s health – through, for example,
adequate newborn care and exclusive breastfeeding – can only be supported within the
framework of maternal health and care.
As indicated, the basis for good health is established even before conception, and is decisive
in the first, formative years. For example, congenital anomalies can be prevented through
various interventions:
1. women’s taking folic acid supplements around the time they conceive, which has a strong
protective effect against the development of neural tube defects in fetuses (59);
2. extending programmes to vaccinate babies and/or young girls against rubella;
3. ensuring the best clinical care of pregnant women with epilepsy or diabetes and
implementing a strategy to combat the risk related to maternal obesity;
4. strengthening the testing of pharmaceuticals before they are marketed and surveillance of
them afterwards;
5. reducing parents’ abuse of recreational drugs such as cocaine and alcohol;
6. providing genetic counselling services; and
7. adopting a precautionary approach to exposure to factors in the environment: reducing high
exposure to by-products of drinking-water chlorination, endocrine-disrupting chemicals,
releases from waste disposal sites and pesticides.
A healthy diet and a clean water supply are crucial to every stage of development, from
before conception through to later life. Poor nutrition is associated with a reduced resistance to
disease, impaired physical and psychological development, and infant morbidity and mortality.
The neonatal period is critical. Experience shows that sophisticated technology is not the
main factor. Neonatal health depends largely on socioeconomic circumstances, access to
appropriate antenatal and delivery services, and parental education. Improvements in the
socioeconomic circumstances of those at greatest risk are effective, combined with measures
to promote health and prevent disease. While the survival of the newborn does not depend
primarily on expensive medical facilities, access to basic health care is crucial.
C H I L D R E N ’ S H E A LT H D E T E R M I N A N T S A N D P O L I C Y R E S P O N S E S
67
Low birth weight (below 2500 g) increases the risk of ill health in the newborn child and in
later life. It is associated with increased rates of coronary heart disease, stroke, hypertension
and non-insulin-dependent diabetes. Its prevalence ranges from around 4% to around 16%
across the Region. Young mothers have a greater tendency to produce low-birth-weight babies.
Such babies are also more frequent among mothers who smoke, and this appears to be the main
factor in the Region. In addition, low birth weight may indicate inadequate maternal nutrition.
Breastfeeding
Breastfeeding is an effective means of improving infants’ well-being at low financial cost. Low
rates and early cessation of breastfeeding:
Uzbekistan
Fig. 10.
Proportion of at
least partially
breastfed
children aged
6 months in 32
countries in the
WHO European
Region, 2000
95
Albania
87
Republic of Moldova
81
Norway
80
Kyrgyzstan
79
Tajikistan
72
Sweden
72
Turkey
71
Kazakhstan
71
Iceland
67
Armenia
63
Finland
51
Belarus
50
Hungary
48
Georgia
44
Estonia
42
Ukraine
41
Israel
41
a
TFYR Macedonia
40
Spain
40
Romania
39
Slovakia
37
Italy
37
Russian Federation
33
Serbia and Montenegro
32
Czech Republic
32
Azerbaijan
30
Lithuania
27
Latvia
26
Netherlands
25
United Kingdom
21
Croatia
17
0
10
20
30
40
50
60
Percentage
70
80
90
100
a
The former Yugoslav
Republic of Macedonia.
Source: European health
for all database (17).
68
T H E E U R O P E A N H E A LT H R E P O R T 2 0 0 5
•
•
•
have important adverse health and social implications for women, children and the
community;
result in greater national expenditure on health care provision; and
increase inequalities in health (60).
In all Member States, too few mothers breastfeed their babies until the age of 6 months (Fig. 10);
WHO recommends exclusive breastfeeding during this period.
Breastfeeding can be supported through a variety of measures, such as counselling,
enlightened employment practices and paid maternity leave. The mass media and education
authorities can play their part by encouraging social norms that support these activities. A
review of the evidence indicates that all forms of extra support for mothers have beneficial
effects on the duration of both exclusive and partial breastfeeding. Extra professional support
is beneficial for any breastfeeding, and lay support is effective in reducing the cessation of
exclusive breastfeeding. Professional support from appropriately instructed personnel showed
benefits to health including a significant reduction in the risk of gastrointestinal infections and
atopic eczema. Research indicates that general support for breastfeeding increases both the
number of mothers involved and the duration (61).
There is consensus on how best to encourage breastfeeding. A Blueprint for Action (60),
funded by the European Commission, builds on the WHO Global Strategy for Infant and Young
Child Feeding (26). It calls for national strategies that emphasize the translation of policy into
practice. Vigilance is required, for instance, to ensure that the International Code of Marketing
of Breast-milk Substitutes (62) continues to be followed.
Feeding practices
Poor feeding practices can be a major cause of malnutrition in young children. The main sign
of this in the Region is low height for age (stunting). The proportion of stunted children aged
under 5 in the period 1997–2003 (see Annex Table 2) was highest in Albania and Tajikistan
(over 35%), but considerable in several other countries with large child populations. Suboptimal
growth patterns are also found among poorer groups in more affluent countries, such as the
United Kingdom.
Stunting increases the risk of ill health, and is associated with impaired cognitive
development and reduced work capacity later in life. Stunting is also a sensitive measure of
poverty. Low-birth-weight infants are more likely to be stunted (63). Poor nutrition in early
life is associated with an increased susceptibility to hypertension, diabetes and CVD. Lowbirth-weight girls are more likely to become stunted mothers, who in turn are at greater risk of
producing low-birth-weight babies (49).
Dietary practices are a function of economic circumstances and social norms. Social norms
can be influenced through education, and communication initiatives reinforced by community
action and professional advice. Changes in the food supply may require governments to take
action at the national level and involve the food-processing industry, education sector, civilsociety organizations and the mass media.
HIV infection
As the number of HIV-infected women in the European Region steadily rises, so does the
transmission of the infection to the newborn. Nevertheless, the Strategic Framework for the
Prevention of HIV Infection in Infants (64) provides an opportunity to eliminate this problem
C H I L D R E N ’ S H E A LT H D E T E R M I N A N T S A N D P O L I C Y R E S P O N S E S
from the Region. Prevention goes beyond clinical care and needs to include a range of care and
protective work, both in health institutions and in the community. The Framework is based
on the experience of countries in the Region. It outlines strategies for implementation at the
country level to achieve the goals set out in the Dublin Declaration on Partnership to Fight
HIV/AIDS in Europe and Central Asia (65). The Framework calls for:
•
•
•
integrating services for the prevention of HIV infection in infants into maternal and child
health and other reproductive health services;
reaching women who have limited or late access to such services; and
expanding high-quality counselling and testing and linking them with other services for
HIV prevention and care.
Environmental determinants
Exposure to harmful factors in the environment is an important contributor to ill health
among children, but major gaps remain in the knowledge of the magnitude and distribution of
the environmental burden of disease among the young. Moreover, there is concern about the
exposure of prospective parents before conception and of the developing fetus.
Environmental conditions clearly influence the health and development of young
children. Those at most risk are among the most disadvantaged in their countries. Poverty is
closely associated with environmental degradation. Exposure to lead, substandard housing,
poor air quality and undernutrition are all characteristics of disadvantaged communities. In
addition, children from poor families are more likely to suffer injuries from road accidents
or in the home. Drowning and fire-related deaths predominate in younger, housebound
children.
Environmental burden of disease
In 2004, the WHO Regional Office for Europe carried out a study of the environmental
burden of disease, the first attempt to assess the impact of the environment on child health
in the European Region (66). The study concentrated on hazards with well-documented
health effects from four major environmental risk factors (outdoor and indoor air pollution,
unsafe water and sanitation, and lead) and injuries. (It did not tackle such areas as the effects
of endocrine-disrupting agents, about which there are still many uncertainties but whose
impact on children’s health raises great concern.) The study aimed to estimate the health gains
achievable from reducing the exposure of the child population in the Region to these hazards.
Using 2001 as the reference year, the study showed that the environmental risk factors and
injuries accounted for one third of the total burden of disease in people aged 0–19 years (66).
It also estimated the number of lives and DALYs that could be saved in the Region by reducing
children’s exposure to these hazards. Overall, among children aged 0–4 years, outdoor air
pollution accounted for 1.8–6.4% of deaths from all causes; acute lower respiratory tract
infections attributable to indoor air pollution, for 4.6% of all deaths and 3.1% of DALYs; and
mild mental retardation resulting from lead exposure, for 4.4% of DALYs. In the group aged
0–14 years, diarrhoea attributable to inadequate water and sanitation accounted for 5.3% of
deaths and 3.5% of DALYs. In the group aged 0–19 years, injuries were the cause of 22.6% of
deaths and 19.0% of DALYs.
In absolute terms, the data showed that, in 2001, up to 13 000 children under 5 died from
outdoor air pollution with particulate matter; 10 000 died as a result of solid-fuel use at
69
70
T H E E U R O P E A N H E A LT H R E P O R T 2 0 0 5
home; and lead poisoning was responsible for over 150 000 DALYs. Poor water and sanitation
accounted for 13 000 deaths in children under 15 years of age.
The burden of disease is much higher in Eur-B and -C than Eur-A, due to varying
combinations of poor housing conditions, a polluted environment and less access to
programmes for disease and injury prevention and health care.
Need for multisectoral response
Children in particularly adverse conditions – such as those who are poor, abandoned, living on
the street, exploited or trafficked, or suffering the consequences of armed conflict – have the
highest risk of injuries and environmental exposures, as well as psychological trauma, acute and
chronic infections and NCDs, impaired growth and development, disability and death. Even
though the understanding of the nature and the amount of health effects produced on children
is incomplete, there is already evidence that action to reduce exposure to environmental risk
factors and to prevent injuries (see key points for decision-makers) can result in substantial
public health gains.
Evidence-based assessment of key points for decision-makers:
preventing injuries in children
Injury is a serious but largely
unappreciated public health problem in
the WHO European Region; the greatest
burden falls on the young and on older
people, and those living in the most
deprived circumstances. The causes of
injury are multifaceted and interrelated,
and thus call for wide-ranging policy
solutions. Educational approaches
are considerably more effective when
they are applied in combination with
legislative measures and environmental
modifications, as their effects interact.
The following approaches should be
considered specifically for children.
Education and skills development
Training programmes in pedestrian
skills, which involve practical
roadside experience, have been
shown to improve children’s skills.
Education targeting both parents
and children has produced good
evidence of behaviour change and
some evidence of casualty reduction.
There is some evidence that
training schemes can improve
children’s behaviour when cycling.
Campaigns to prevent home
accidents by educating parents
can lead to some reductions in
medically attended injuries in
young children or to behavioural
and environmental changes.
Promoting the use of safety devices
There is some evidence of a reduction
in injuries as a result of programmes
to distribute smoke alarms.
The evidence of the effectiveness
of bicycle-helmet programmes is
overwhelming. Promotional campaigns,
particularly those employing multiple
intervention strategies, can be
effective in increasing helmet use.
Educational campaigns on child
restraints in vehicles (seat-belts,
etc.) lead to an increase in observed
restraint use. No evidence has been
shown of effects on injury outcomes,
however. In buildings, window bars
are effective in decreasing falls.
Supportive home visits
There is some evidence that advice
and support, provided at home
by a visiting health professional
or community volunteer, leads to
behavioural and/or environmental
change that reduces hazards.
Modification of the environment
Community-wide safety programmes
(using localized traffic calming and
a range of other measures, such as
speed bumps and roundabouts)
are effective in reducing accidents,
particularly among child pedestrians
and cyclists. Speed-reduction
zones are effective in reducing
both traffic speed and accidents.
Source: Health Evidence Network (67).
On the basis of the evidence, the health and environment ministers in the WHO European
Region, gathered at the Fourth Ministerial Conference on Environment and Health in June
2004, agreed to step up action to protect children’s health from harmful environmental
exposures. They adopted the Children’s Environment and Health Action Plan for Europe (68),
which set four regional priority goals for action addressing the diseases and disability arising
from exposure to chemical, physical and biological agents. The Action Plan is a framework
C H I L D R E N ’ S H E A LT H D E T E R M I N A N T S A N D P O L I C Y R E S P O N S E S
within which countries can make national action plans suited to their circumstances and needs
(69).
Behavioural determinants
A recent WHO report provides revealing insight into the lives of young people (70). It gives
the results of the most recent survey of the Health Behaviour in School-aged Children (HBSC)
study, covering almost 162 000 young people aged 11, 13 and 15 years in 35 countries in the
WHO European Region and North America. In addition to social and economic factors, the
report covers alcohol, tobacco and cannabis use, injuries, physical activity, bullying and sexual
behaviour.
Smoking
Smoking is a habit that is usually established or reinforced during the teenage years; some 80%
of adult smokers started before the age of 18. Weekly smokers comprise 11–57% of boys and
12–67% of girls aged 15 (70); most of them smoke daily. Although boys tend to start smoking at
an earlier age, the proportion of girls who smoke is increasing in a number of countries. More
boys than girls smoke at age 15 in eastern Europe, while the opposite is the case in northern
and western parts of the Region. The rates are similar for both genders in southern and central
European countries.
The most effective public health interventions available are increasing the price of cigarettes
and banning cigarette advertising, as described in Part 2 (p. 33). There is little evidence that
school-based programmes are effective in preventing young people from starting to smoke,
although there is some limited support for the effectiveness of community interventions in
this task (60). Clearly, more needs to done to tackle tobacco use among young people. Success
depends on using the full range of policy instruments available to governments: taxation,
smoking controls in public places, gender-specific programmes targeted at adolescents, massmedia campaigns, and smoking cessation services all have a part to play in combating the
tobacco epidemic.
Alcohol
Alcohol is a regular feature in the lives of many European adolescents. Almost 30% of 15-year-olds
report regular drinking (70), although there are substantial differences across the Region. Young
people in many countries appear to start drinking at an earlier age than previously. Research has
found that this is associated with an increased likelihood of both alcohol dependence and alcoholrelated injury later in life. Over 50% of 15-year-olds report weekly drinking in England, the
Netherlands and Wales, but the rates are below 17% in France, Finland, Latvia and Portugal. In all
countries, proportions of weekly drinking are higher among boys than girls.
Hazardous and harmful alcohol use can be both a symptom and a cause of mental health
problems. It is frequently associated with violence by young people, which contributes to family
and community stress. Alcohol is associated with the deaths of 55 000 young people in the
European Region each year, and many intervention projects have been designed to promote
sensible drinking among them. Many programmes have adopted educational approaches, often
in school settings. Although education may change attitudes and beliefs, on its own it tends to
have little impact on drinking behaviour.
The formula for success is similar to that in other areas: a mix of policy initiatives is required to
bring about real change. The available policy tools include: taxation, legal age limits on purchase
71
72
T H E E U R O P E A N H E A LT H R E P O R T 2 0 0 5
and/or consumption, restrictions on advertising, controls on drinking in public places, massmedia advocacy and education.
Illicit drug use
Cannabis use is common in some countries in the Region, such as England and Switzerland
(70). Although girls are less likely to use cannabis than boys, this difference may shrink in
the future. A growing proportion of adolescents perceives the recreational use of cannabis as
normal behaviour.
Heavy consumption, defined as using cannabis more than 40 times within a year, may be
associated with depression and risk taking. Specific interventions should focus on the relatively
small numbers of young people reporting heavy use, as they may well be at particular risk.
In addition, evidence from some countries indicates that injecting drug use is starting at an
earlier age. The average age at first injection in eastern European and central Asian countries is
16–19 years, although some adolescents start before the age of 15. Injecting drug users, many of
whom are young, are estimated to comprise up to 1% of the population in some countries of the
Region, and up to 5% in some eastern European cities.
Physical activity and nutrition
Investment in the next generation is a matter of encouraging positive, healthy lifestyles, as well
as tackling ill health. Physical activity and a healthy diet form part of the foundation for mental
and physical well-being. Physical activity is an important factor in promoting cardiovascular
fitness, maintaining normal body weight and supporting optimal skeletal growth and
development. Unfortunately, substantial numbers of young people in all countries in the HBSC
survey fall short of current guidelines, which recommend 60 minutes of physical activity per
day. In addition, activity levels decline with age, particularly among girls (70).
There is general consensus that good nutritional practices and physical activity should be
encouraged as early as possible in life, and that parents’ knowledge, attitudes and behaviour
are important in creating role models (51). At present, work to improve nutrition and increase
exercise has tended to focus on educational interventions in schools throughout the Region,
such as the programme carried out by the European Network of Health Promoting Schools
(71). There is some evidence that multifaceted school-based programmes that combine the
promotion of physical activity, the modification of dietary intake and the reduction of sedentary
behaviour, may help to reduce obesity in schoolchildren, particularly girls (72). Although
messages on healthy eating are reaching adolescents, interventions are needed to help them
translate these messages into behaviour.
Any strategy designed to improve physical activity among young people must take account
of a number of factors. Young people’s views are critical. They can describe the barriers to
exercise in a way that is sensitive to their culture and age group. Gender differences must also be
considered. The social aspects of participation are of particular significance, as are access to and
the costs of using exercise facilities.
People are likely to maintain the eating habits developed during childhood and adolescence
into adulthood. Good nutrition helps to reduce the incidence of overweight and obesity,
dental caries and anaemia. A high-quality diet promotes proper growth and development, and
contributes to the young person’s ability to learn. Diet is subjected to numerous social, cultural
and commercial influences. Peers often have greater influence than parents, and advertising
often targets children.
C H I L D R E N ’ S H E A LT H D E T E R M I N A N T S A N D P O L I C Y R E S P O N S E S
Fruit and vegetable consumption among children is worryingly low across the Region. The
HBSC survey (70) showed that only 30% of boys and 37% of girls aged 13–15 years eat fruit
every day. Vegetable consumption shows a similar pattern. Young people from less affluent
backgrounds have a greater tendency to skip breakfast, eat fewer fruits and vegetables, and eat
sweets and snacks more often.
Teenage pregnancy
Teenage pregnancy and early parenthood can lead to poor educational achievement, poor
physical and mental health, poverty and social isolation for mothers and their children. Rates
of teenage pregnancy vary across the European Region, with eastern countries in general
experiencing higher rates than western ones, although patterns vary considerably. The rates
in most western European countries range between 13 and 25 pregnancies per 1000 girls aged
15–19 years and peak at around 50 per 1000. Some of the countries of central and eastern
Europe show similar figures. Several other countries have rates 2–4 times higher, peaking at
over 100 per 1000 girls in Ukraine.
Factors that are relatively strongly associated with teenage birth rates in countries across the
Region include: rates of teenage marriage, overall wealth and income distribution, the average
length of education and the influence of religion. Socioeconomic disadvantage can be both a
cause and an effect of young parenthood. As with other threats to children’s health, teenage
pregnancy requires a broad response (see key points for decision-makers).
Evidence-based assessment of key points for decision-makers:
teenage pregnancies
Experience in the European
Region has shown that a focus on
the following may be effective in
reducing the rates and negative
consequences of teenage pregnancy:
• preventing unintended conceptions,
•
•
•
rather than reducing pregnancy
levels through higher abortion rates;
strengthening secondary preventive
efforts – education, employment
and support – to help mothers and
children, particularly single mothers;
integrating preventive efforts
with other related services; and
providing sex education before
young people become sexually
active, with open attitudes and
a positive approach to sexual
health and relationships.
Policies should:
1. focus on improving contraceptive
use and at least one other behaviour
likely to prevent pregnancy and
sexually transmitted infections;
2. provide long-term services and
interventions tailored to meet the
needs of young people, particularly
those in high-risk groups;
3. provide clear and
unambiguous information;
4. include the development of
interpersonal skills in, for example,
negotiation and refusal;
5. provide timely intervention,
for example, when an
adolescent receives a negative
pregnancy test from a clinic;
6. build programmes on theory-driven
approaches with clear behavioural
goals and outcomes, using
participatory teaching methods;
7. ensure that interventions
and services are accessible
by young people;
8. select and train staff committed
to programme goals and
respectful of confidentiality;
9. work with teenage opinion leaders,
including those in peer groups;
10. make sure interventions are
appropriate to the age group;
11. encourage a local culture
permitting the discussion of sex,
sexuality and contraception; and
12. coordinate services to prevent
pregnancy with other services
for young people, and work in
partnership with the community.
Source: Health Evidence Network (73).
Family and community determinants
Strengthening families and the communities in which they live is at the heart of child health
and development. As mentioned in Part 2, family structure has changed noticeably in many
societies over recent decades. Single-parent families, or families where one of the parents is not
73
74
T H E E U R O P E A N H E A LT H R E P O R T 2 0 0 5
the birth parent, have increased. The divorce rate has escalated, as has the number of children
born outside marriage. Migration from the countryside to cities continues, often leaving behind
the traditional support network of the extended family. In many countries, mothers are more
likely to hold paid jobs than in previous generations. As a consequence of all these factors, the
social system that used to buttress young families is no longer available to the same extent in
many parts of the WHO European Region.
Need for health promoting home environments
How a family functions is integral to the healthy development of young people. The definition of
a family has widened; there is no blueprint for the ideal parent. The quality of the relationships
within a family is more important than its structure. Positive relationships with parents increase
feelings of well-being and decrease the likelihood of health damaging behaviour, such as smoking.
Infants and young children in particular need a safe, stable and supportive home environment.
Creating the right climate for their development is an investment with lifetime dividends: it
should not only protect children from physical challenges to health but also offer the right
support for their physical, social and emotional growth.
Families operate within the context of the community and the wider environment. A range
of factors determines every family’s access to health-related products and services, such as
time, money, transport, knowledge and skills, and the availability of products and services.
The resources available limit the action that families can take. Education, employment and the
material conditions of life are crucial to the family’s ability to maintain and improve its health.
People see health as a luxury when life is a struggle for survival.
As mentioned, the most disadvantaged families need the greatest support. Any investment
in better housing, improved educational opportunities or better nutrition will strengthen the
chances of children in poor families for healthy lives. Targeted welfare benefits can ameliorate the
worst ravages of poverty, if they are managed so as to benefit children directly.
Prevention of child abuse (74–80)
Investment in children’s health should include the prevention of abuse. Child abuse falls into four
broad categories:
1. neglect: the persistent or severe neglect of a child, or the failure to protect a child from
exposure to any kind of danger;
2. physical abuse: actual or likely physical injury to a child, or failure to prevent injury or
suffering;
3. sexual abuse: actual or likely sexual exploitation of a child; and
4. emotional abuse: an actual or likely severe adverse effect on the emotional and behavioural
development of a child caused by persistent or severe emotional maltreatment or rejection.
No reliable information exists to determine trends in the occurrence of child abuse. Observed
changes may be due to changes in data collection. Nevertheless, mortality registers showed
a dramatic rise in infant homicide and manslaughter in many countries in the eastern half of
the WHO European Region, particularly in the CIS, in the 1990s. This may be associated with
the disruption of community, health and social services brought about by political, social and
economic change; infant deaths from child abuse in the western half of the Region remained
lower and relatively constant in that period. Since 2000, mortality has fallen again in central and
eastern Europe, possibly owing to the redevelopment of health and social services.
C H I L D R E N ’ S H E A LT H D E T E R M I N A N T S A N D P O L I C Y R E S P O N S E S
The prevention of child abuse should be viewed in the broader context of child welfare in
the family and community. From a health service perspective, this requires the integration of
good practices (such as programmes for home visitation and other forms of family support) in
services for families and children, including aiming services at families with a high number of
risk factors for child abuse. The risk factors are both individual and societal. For example, young
children are most at risk of physical abuse, while sexual abuse is more likely among adolescents.
Boys are more often victims of beatings, while girls are at higher risk of sexual abuse and
educational neglect. In addition, child abusers frequently have a history of being abused and of
substance abuse. Societal-level risk factors include household overcrowding, insufficient family
income, the presence of other violent relationships in the home, and high rates of poverty and
weak social networks in communities.
Caution is needed, however, in using a risk-based approach. Focusing on one or a
combination of risk factors for child abuse is likely to stigmatize families that fit the profile,
which may translate into marginalization of the families and their children, and to overlook
abuse in other families. Moreover, as no single risk factor sufficiently predicts child abuse,
prevention is most likely to be effective if it targets both individual and societal risks
simultaneously.
Underlying social determinants
The magnitude of the unnecessary ill health and death caused by social factors and widening
inequalities give priority to reducing poverty and achieving the Millennium Development
Goals (11) (see p. 47). In this context, WHO has re-emphasized that interventions
succeed in reducing disease and saving lives only when they take adequate account of the
social determinants of health (10). Although much is known about these causes of the
causes of ill health, this knowledge still needs further development, consolidation and
communication, so that more effective action can follow. To meet this need, WHO launched
the Commission on Social Determinants of Health in March 2005; its task is to develop
practical recommendations on how to improve health by acting on its social determinants, for
presentation in 2008 (81).
Need to tackle poverty and inequality
The most effective way to protect and improve child health in all countries is to eliminate
poverty, socioeconomic inequality and their consequences (58). The health effects of material
deprivation – for example, poor nutrition, unhealthy environments and lack of access to highquality health care – have been discussed. Although absolute poverty that directly threatens
people’s lives has almost been eliminated in the more affluent countries in the Region, relative
poverty remains, in which certain members of society do not enjoy the living standards
available to their fellow citizens. Any attempt to define overall poverty needs therefore to take
account of both absolute and relative poverty.
In the low- and middle-income countries in the eastern half of the Region, absolute child
poverty is frequently observed, but appropriate individual-level statistics are difficult to obtain.
As an alternative, UNICEF (82) assessed the risks of poverty for children at the macro level,
defining it as a gross national income (GNI) per head of US$ 765 or less in 2003, or a stagnant
or negative average annual growth rate in GDP per head in 1990–2003. Six CIS countries were
assessed to have met the criteria for poverty as a threat to childhood around 2003: Georgia, the
Russian Federation, Tajikistan, Turkmenistan, Ukraine and Uzbekistan. The UNICEF report
75
76
Fig. 11. Children
living in relative
poverty in selected
affluent countries in
the WHO European
Region, 2005
T H E E U R O P E A N H E A LT H R E P O R T 2 0 0 5
Italy
16.6
Ireland
15.7
Portugal
15.6
United Kingdom
15.4
Spain
13.3
Poland
12.7
Greece
12.4
Germany
10.2
Austria
10.2
Netherlands
9.8
Luxembourg
9.1
Hungary
8.8
Belgium
7.7
France
7.5
Switzerland
6.8
Czech Republic
6.8
Sweden
4.2
Norway
3.4
Finland
2.8
Denmark
2.4
0
Source: data from UNICEF
Innocenti Research Centre (83).
2
4
6
8
10
12
14
16
18
Percentage
(82) emphasizes, however, that poverty is more than material deprivation and has different
dimensions and implications in children than adults.
As one moves westward, towards the higher-income countries in the Region, the form
and statistical indicators of poverty change. A 2005 review of child poverty in rich countries
by UNICEF (83) found that the proportion of children aged under 18 years living in relative
poverty in the industrialized world actually rose over the last decade, no matter which of the
commonly used measures of poverty was applied. Fig. 11 shows the percentage of children
living in relative poverty (households with income below 50% of the national median income)
in 20 countries in the Region designated as affluent by UNICEF.
Fig. 11 shows rates of child poverty ranging from under 5% in Scandinavia to over 15% in
Ireland, Italy and the United Kingdom. Such variation reflects differences in national policies,
interacting with social changes. Higher government spending on family and social benefits
is clearly associated with lower rates of child poverty. In the countries with the lowest levels,
governments reduce by 80% or more the child poverty that would result from leaving market
forces to themselves (83).
Moreover, there is a social gradient in health from the poorest to the richest. Where material
deprivation is severe, a social gradient could arise from degrees of absolute deprivation, but
the gradient in the more affluent countries reflects relative deprivation, which restricts people’s
right to realize their health potential in terms of capabilities and functioning. Both physical and
psychosocial needs are therefore likely to be important to the gradient in health (84).
In particular, there is strong evidence that diet, smoking, alcohol use and physical activity
are associated with social and economic circumstances, and ultimately with health outcomes
C H I L D R E N ’ S H E A LT H D E T E R M I N A N T S A N D P O L I C Y R E S P O N S E S
in adults. As far as children’s health is concerned, solid knowledge is available on the role of the
proximate determinants of children’s health (9), especially in mortality, malnutrition and other
problems in early childhood. The causes of the disparities in these proximate determinants
are clear: social inequalities, which interact with other determinants. In addition, the evidence
suggests that some mental health problems – such as aggressive behaviour, low self-esteem
and inability to cope with life’s challenges – are indirectly related to low socioeconomic status.
Thus, socioeconomic conditions may also influence health through the psychosocial impact of
relative poverty.
Taking action on the social determinants of health is imperative for all countries. Such action
should include the relief of poverty but also pursue the broader aim of improving people’s living
and working conditions. The task also requires knowledge of the health effects of the social and
economic policies of all sectors that can be translated into action; the WHO Commission on
Social Determinants of Health is expected to add to this knowledge. While the health sector will
continue to have a pivotal role, action is required from many sectors of government and society.
Health is a multisectoral endeavour, which will yield multisectoral benefits. The aim is to
make healthy choices the easier choices for people to make.
77
78
T H E E U R O P E A N H E A LT H R E P O R T 2 0 0 5
Main factors in successful implementation
of policies and interventions
Making effective policy depends on a number
of factors, which determine the usefulness,
effectiveness and efficiency of any subsequent
plans for implementation. Evidence-based policy
is now more feasible than ever before. A number
of recurring themes emerge from the knowledge
about how best to improve the health and
development opportunities for children.
•
•
•
•
•
•
•
Despite wide differences in the
health problems of children
across the WHO European Region,
successful health promotion and
disease prevention programmes
share some common factors. The
most successful interventions:
• are created as part of
comprehensive national planning
Accurate and reliable information must
and are based on solid evidence;
provide the basis for planning, monitoring and
• address both the broad
evaluation of policies and programmes.
determinants of ill health and
Policy without implementation is meaningless.
particular risk factors;
The capacity to deliver must be considered
• involve multisectoral,
multifaceted and multilevel
when policy is formulated.
action by government and other
Children themselves should be involved in
stakeholders, using the whole array
designing policies and programmes.
of available policy instruments; and
Policy goals and programme objectives must be
• target the populations in
clear and unambiguous.
most need, and are adapted
Educational approaches alone are likely to be
to local needs, resources and
circumstances.
of limited effectiveness. They need to form part
of a wide set of initiatives that use the full set of
policy instruments available to decision-makers.
Although the health sector is important, it is only one player in the quest for better health.
Multisectoral action is essential, and a mechanism is needed to coordinate work across
ministries.
Facilities and programmes for children must take account of their culture, attitudes and
beliefs. Child-friendly services are effective services.
This report has presented a framework of key health indicators of the burden of disease
and determinants of health, and highlighted, mainly by the way of example, policies and
programmes for disease prevention and health promotion. Here it is important to address the
question of what the evidence shows are the common factors for success in practice, across
interventions and populations. These factors are related to both the types of interventions and
the contexts in which they are carried out.
A review of such evidence by the Health Evidence Network (85) points to the following
ingredients of success.
Approach and scope
Two basic approaches to health promotion and disease prevention tackle:
1. the underlying determinants of health, such as poverty and socioeconomic inequality; or
2. specific risk factors for specific health outcomes, such as lack of physical activity, some forms
M A I N FA C T O R S I N S U C C E S S F U L I M P L E M E N TAT I O N O F P O L I C I E S A N D I N T E R V E N T I O N S
of obesity or lack of blood pressure control (which leads to hypertension), which increase the
risk of atherosclerosis and therefore coronary heart disease.
The approaches are interrelated, since poverty and socioeconomic inequality are key underlying
determinants of many risk factors. Nevertheless, they call for different types of action. The
second approach encourages health education focused on individuals and aimed at increasing
their awareness of and involvement in taking proper care of their health. Action on the first
approach requires a more comprehensive, societal approach, using the democratic process to
foster changes in policy, leading to the fair distribution of resources.
In general, the available evidence suggests that the most effective public health programmes,
for children and adults alike, are those carried out by the government – and supported by
society in general by promoting policy change – to alleviate the harm done to health by poverty
and to increase social equality.
Interventions that address multiple broader issues are more likely to succeed. The health
promotion interventions that are least likely to work:
•
•
•
deal with single issues;
deliver a negative message; and
address only one setting.
An example would be campaigns in schools telling students not to smoke.
In addition, effective interventions use the whole array of available policy instruments, either
mainly on the responsibility of a country’s government or involving it. Examples given in this
report include tobacco and alcohol use, and nutrition, physical activity and obesity.
There is also evidence that general health promotion campaigns are more effective when they
are multifaceted and multilevel: that is, when there are simultaneous, multidimensional efforts
at the national, local and individual levels.
Need for evidence
Strong and credible scientific evidence that a public health intervention is effective is a prerequisite for success. At least two types of evidence are required:
1. evidence that an intervention in itself works; and
2. evidence that the intervention programme works over time and in different epidemiological
circumstances, health systems and cultural contexts.
Little rigorous research is documented on interventions’ adaptability. Such systematic research
is urgently needed, as the coverage of effective interventions tends to be lowest in poor
countries and the poorest populations.
Because interventions must be adapted to local circumstances, the capacity of the health
system at different levels in the country should be assessed. For example, how far are regional
needs in child health taken into account at the national level? How are resources redirected
to programmes with a high political profile, such as those to prevent AIDS? Other factors to
consider include:
•
•
the degree of development and the organization of a country’s health system (for example,
national systems versus local, private systems);
the health system’s strengths, weaknesses, infrastructure, current coverage and utilization;
79
80
T H E E U R O P E A N H E A LT H R E P O R T 2 0 0 5
•
•
•
the population’s patterns of seeking health care, which are influenced by socioeconomic and
cultural factors;
the various options for financing; and
the human and financial resources available.
In addition, the availability of relevant and reliable data on the population targeted for
intervention is a prerequisite for knowing whether the intervention should be made and
determining its effectiveness. Such data need to be collected at the national, regional and/or
local levels to assess the epidemiological situation, political willingness to act, the capacity of
the health system to take part and the preferences of the community. Only when such data are
available are public health interventions justifiable.
Tactics
Targeting particular population groups with interventions is key. Certain groups of children
and adults are more vulnerable than others to particular hazardous behaviour, such as smoking,
alcohol, poor diets and lack of exercise. Such populations include people living in poverty,
cultural minority groups, the socially excluded and those with mental health problems.
The people who plan and implement programmes should take account of the age and
developmental stage of the target population. For example, programmes on drug use may focus
on prevention among children aged 9–10 years and the minimization of harm among older
teenagers, who may already be using illegal drugs.
In addition, effective interventions take account of cultural, religious and gender factors. For
example, different approaches to some issues, such as the prevention of pregnancy, may need to
be taken for the male and female populations. The approach to other issues – such as reducing
smoking by banning cigarette advertising and increasing the prices of tobacco products – may
be the same for both genders, even though their behaviour may differ.
Further, successful implementation is associated with a perception by the public that the
health problem represents significant burden to society, families and individuals, as indicated
by prevalence, economic impact and high political profile. In addition, programmes should
account for different groups’ varying perceptions of risks. In many societies, for example, adults
see smoking as a threat to health, while adolescents value its immediate attractions more than
the long-term risks (70).
There is some evidence for the effectiveness of mass-media involvement. Important factors
appear to be the education level of the population, the duration of delivery and the intensity of
media programmes, and the credibility of the source of the information given.
Conclusion
To be most successful, public health interventions need to address all the direct and indirect
influences on children’s health, and take action on many fronts and in many sectors.
Implementation strategies are most successful when they are based on comprehensive national
planning that:
•
•
•
involves children themselves;
utilizes the contributions of families and communities, schools, the mass media, the health
system and government; and
uses such tools as policy, legislation and regulations.
M A I N FA C T O R S I N S U C C E S S F U L I M P L E M E N TAT I O N O F P O L I C I E S A N D I N T E R V E N T I O N S
This work can take the form of a national joint plan or programme (see success story).
All these elements of success fall under the four guiding principles of the European strategy
for child and adolescent health and development (15) (see p. 48):
•
•
•
SUCCESS STORY
•
equity: addressing inequalities and facilitating the fulfilment of human rights, including
access to appropriate services for those in greatest need;
intersectoral action: adopting an intersectoral public health approach that addresses the
fundamental determinants of health;
involvement of the public and young people: engaging them in the planning, delivery and
monitoring of policies and services; and
a life-course approach: making policies and implementing programmes that reflect the
health challenges at each stage of growth and development.
Ireland’s Programme of Action for Children
Ireland’s Programme of Action for Children (86)
originated as Best Health for Children, a multisectoral
initiative jointly owned by all the health boards of
Ireland and endorsed by all their chief executive
officers, key nongovernmental organizations for
children and young people, and the Government
through the Department of Health and Children.
Having identified issues needing to be addressed,
the initiative seeks to evaluate potential intervention
programmes as a matter of routine before recommending
them as adopted policies. By this route, it has yielded
a number of best-practice documents based on
evidence of effectiveness gained by evaluation (87).
Best Health for Children has now been drawn into the
Irish Health Boards Executive as one of its joint national
programmes. As the Programme of Action for Children,
its task is to manage child-related projects, ensuring
equity of approach and tailoring to local needs.
In sum, success in the planning, implementation and evaluation of interventions in different
contexts requires an understanding of health problems and interventions in terms of the
conceptual framework described in Part 1 of this report, which emphasizes the complex
relationships among multiple general determinants, specific risk factors and health. This broad
view of health implies that public health authorities must not only look at the known risk factors
and interventions but also look beyond them to the underlying environmental, behavioural
and social factors that influence health outcomes in different ways in different circumstances.
Understanding and applying this knowledge comprise part of the art and science of public
health.
81
82
T H E E U R O P E A N H E A LT H R E P O R T 2 0 0 5
References
1. Convention on the Rights of the Child. Geneva, Office of the United Nations High
Commissioner for Human Rights, 1989 (http://www.unhchr.ch/html/menu3/b/k2crc.htm,
accessed 25 May 2005).
2. The world health report 2003 – Shaping the future. Geneva, World Health Organization,
2003 (http://www.who.int/whr/2003/en, accessed 25 May 2005).
3. Braveman P, Gruskin S. Poverty, equity, human rights and health. Bulletin of the World
Health Organization, 2003, 81(7):539–545.
4. Marmot M, Wilkinson R. Social determinants of health. New York, Oxford University Press,
1999.
5. Momas I et al. Rapport de la Commission d’orientation du plan national santéenvironnement. Paris, Agence Française de Sécurité Sanitaire Environnementale, 2004.
6. Labonte R. Globalization, trade and health: unpacking the links and defining health policy
options. In: Hofrichter R, ed. Health and social justice: politics, ideology and inequity in the
distribution of disease. San Francisco, Jossey Bass, 2003.
7. Lee J-W. Child survival: a global health challenge. Lancet, 2003, 362(9389):262.
8. The world health report 2005 – Make every mother and child count. Geneva, World Health
Organization, 2005 (http://www.who.int/whr/2005/en, accessed 25 May 2005).
9. Wagstaff A et al. Child health: reaching the poor. American Journal of Public Health, 2004,
94(5):726–736 (http://www.ajph.org/cgi/content/full/94/5/726, accessed 25 May 2005).
10. Lee J-W. Public health is a social issue. Lancet, 2005, 365(9464):1005–1006.
11. United Nations. UN Millennium Development Goals. New York, United Nations, 2000
(http://www.un.org/millenniumgoals, accessed 15 February 2005)
12. Determinants of Health Working Group synthesis report. Ottawa, Health Canada, 2003
(http://www.hc-sc.gc.ca/english/care/health_forum/publications/finvol2/determinants,
accessed 25 May 2005).
13. Coleman RJ. Reducing social inequalities in health among children and young people.
Brussels, European Commission, 2002 (http://europa.eu.int/comm/dgs/health_consumer/
library/speeches/speech156_en.pdf, accessed 25 May 2005).
14. The health of children and adolescents in WHO’s European Region. Copenhagen, WHO
Regional Office for Europe, 2003 (WHO Regional Committee for Europe resolution EUR/
RC53/R7; http://www.euro.who.int/governance/resolutions/2003/20030925_3, accessed 25
May 2005).
15. European strategy for child and adolescent health and development. Copenhagen, WHO
Regional Office for Europe, 2005 (http://www.euro.who.int/Document/RC55/edoc06.pdf,
accessed 28 June 2005).
REFERENCES
16. A decade of transition: the MONEE Project CEE/CIS/Baltics. Florence, UNICEF Innocenti
Research Centre, 2001 (Regional Monitoring Report No. 8; http://www.unicef-icdc.org/
publications/pdf/monee8/eng/3.pdf, accessed 25 May 2005).
17. European health for all database [online database]. Copenhagen, WHO Regional Office for
Europe, 2005 (http://www.euro.who.int/hfadb; accessed 25 May 2005).
18. Rigby M, Köhler L. Child Health Indicators of Life and Development (CHILD): report to the
European Commission. Keele, Centre for Health Planning and Management, 2000 (http://
www.europa.eu.int/comm/health/ph/programmes/monitor/fp_monitoring_2000_frep_
08_en.pdf, accessed 25 May 2005).
19. Rigby MJ et al. Child health indicators for Europe – A priority for a caring society. European
Journal of Public Health, 2003, 13(Suppl. 3):38–46 (http://www3.oup.co.uk/eurpub/hdb/
Volume_13/Supplement_01/13s10038.sgm.abs.html, accessed 25 May 2005).
20. Mathers C et al. Global burden of disease in 2002: data sources, methods and results. Geneva,
World Health Organization, 2004 (http://www3.who.int/whosis/menu.cfm?path=evidenc
e,burden,burden_gbd2000docs,burden_gbd2000docs_DP54&language=english, accessed
27 April 2005).
21. WHO Global InfoBase [online database]. Geneva, World Health Organization, 2005
(http://www.who.int/ncd_surveillance/infobase/web/en/, accessed 25 May 2005).
22. Reproductive, maternal and child health in eastern Europe and Eurasia: a comparative report.
Atlanta, GA, Centers for Disease Control and Prevention, and Calverton, MD, ORC Macro,
2003 (http://www.measuredhs.com/pubs/pdf/OD28/00FrontMatter.pdf, accessed 25 May
2005).
23. Integrated management of pregnancy and childbirth. Copenhagen, WHO Regional Office for
Europe, 2004 (http://www.euro.who.int/pregnancy/manuals/20030129_7, accessed 25 May
2005).
24. Integrated Management of Childhood Illness. Copenhagen, WHO Regional Office for
Europe, 2005 (http://www.euro.who.int/childhealtdev/imci/20020319_2, accessed 25 May
2005).
25. Core information for the development of immunization policies. 2002 update. Geneva,
World Health Organization, 2002 (http://www.who.int/vaccines-documents/DocsPDF02/
www557.pdf, accessed 25 May 2005).
26. Global Strategy for Infant and Young Child Feeding. Geneva, World Health Organization,
2003 (http://www.who.int/child-adolescent-health/New_Publications/NUTRITION/gs_
iycf.pdf, accessed 25 May 2005).
27. WHO mortality database [online database]. Geneva, World Health Organization, 2005
(http://www3.who.int/whosis/menu.cfm?path=whosis,mort&language=english, accessed
25 May 2005).
28. Steliarova-Foucher E et al. Geographical patterns and time trends of cancer incidence and
survival among children and adolescents in Europe since the 1970s (the ACCIS project): an
epidemiological study. Lancet, 2004, 364(9451):2097–2105.
83
84
T H E E U R O P E A N H E A LT H R E P O R T 2 0 0 5
29. Nelson LJ, Wells CD. Global epidemiology of childhood tuberculosis. The International
Journal of Tuberculosis and Lung Disease, 2004, 8(5):636–647 (http://thesius.ingentaselect.
com/vl=1406159/cl=55/nw=1/rpsv/ij/iuatld/10273719/v8n5/s23/p636, accessed 25 May
2005).
30. Donald PR. Childhood tuberculosis: the hidden epidemic. The International Journal of
Tuberculosis and Lung Disease, 2004, 8(5):627–629 (http://thesius.ingentaselect.com/
vl=1406159/cl=55/nw=1/rpsv/ij/iuatld/10273719/v8n5/s21/p627, accessed 25 May 2005).
31. Complementary feeding of young children in developing countries. A review of the current
scientific knowledge. Geneva, World Health Organization, 1998 (http://whqlibdoc.who.
int/hq/1998/WHO_NUT_98.1.pdf, accessed 25 May 2005).
32. Making Pregnancy Safer in the European Region. Copenhagen, WHO Regional Office for
Europe, 2005 (http://www.euro.who.int/pregnancy, accessed 25 May 2005).
33. International Council for the Control of Iodine Deficiency Disorder. IDD problem
statement. Charlottesville, University of Virginia, 2004 (http://www.people.virginia.edu/
%7Ejtd/iccidd/aboutidd.htm#problem; accessed 25 May 2005).
34. de Benoist B et al. Iodine status worldwide: WHO Global Database on Iodine Deficiency.
Geneva, World Health Organization, 2004 (http://nutrition.tufts.edu/conferences/
childhood/iodine/iodinewho.pdf, accessed 25 May 2005).
35. Meltzer H et al. Mental health of children and adolescents in Great Britain. London, Office of
National Statistics, 2000.
36. Barlow J. Systematic review of effectiveness of training programmes in improving behavioural
problems in children aged 3–10 years. Oxford, Department of Public Health. Health Services
Research Unit, 1999.
37. Health Evidence Network. For which strategies of suicide prevention is there evidence of
effectiveness? Copenhagen, WHO Regional Office for Europe, 2004 (http://www.euro.who.
int/eprise/main/WHO/Progs/HEN/Syntheses/suicideprev/20040712_2, accessed 25 May
2005).
38. Mental Health Action Plan for Europe. Facing the Challenges, Building Solutions.
Copenhagen, WHO Regional Office for Europe, 2005 (http://www.euro.who.int/
document/mnh/edoc07.pdf; accessed 25 May 2005).
39. Royal College of Psychiatrists. Prevention in psychiatry: report of the Public Policy
Committee Working Party. London, Royal College of Physicians, 2002.
40. Birchwood M et al. Early intervention in schizophrenia. British Journal of Psychiatry, 1997,
170:2–5.
41. Tamburlini G, von Ehrenstein O, Bertollini R, eds. Children’s health and environment: a
review of evidence. Copenhagen, European Environment Agency, 2002 (Environmental
Issue Report No. 29; http://www.euro.who.int/document/e75518.pdf, accessed 25 May
2005).
42. Masoli M et al. Global burden of asthma – Summary. Bethesda, MD, Global Initiative for
Asthma, 2004 (http://207.159.65.33/wadsetup/boa_sum.pdf , accessed 25 May 2005).
REFERENCES
43. Businco L et al. An ESPACI position paper. Hydrolysed cow’s milk formulae. Allergenicity
and use in treatment and prevention. Pediatric Allergy and Immunology, 1993, 4:101–111.
44. Hide DW et al. Allergen avoidance in infancy and allergy at 4 years of age. Allergy, 1996,
51:89–93.
45. Bronchial asthma. The scale of the problem. Geneva, World Health Organization, 2000 (Fact
Sheet No. 206; http://www.who.int/mediacentre/factsheets/fs206/en/, accessed 25 May
2005).
46. Künzli N et al. Public-health impact of outdoor and traffic-related air pollution: a European
assessment. Lancet, 2000, 356(9232):795–801.
47. Krzyzanowski M, Kuna-Dibbert B, Schneider J, eds. Health effects of transport-related air
pollution. Copenhagen, WHO Regional Office for Europe, 2005 (http://www.euro.who.
int/InformationSources/Publications/Catalogue/20050601_1, accessed 25 May 2005).
48. Bruce N, Perez-Padilla R, Albalak R. Indoor air pollution in developing countries: a major
environmental and public health challenge. Bulletin of the World Health Organization, 2000,
78:1078–1092.
49. Robertson A et al., eds. Food and health in Europe: a new basis for action. Copenhagen,
WHO Regional Office for Europe, 2004 (WHO Regional Publications, European Series,
No. 96; http://www.euro.who.int/eprise/main/who/InformationSources/Publications/
Catalogue/20040130_8, accessed 25 May 2005).
50. Kurscheid T, Lauterbach K. The cost implications of obesity for health care and society.
International Journal of Obesity and Related Metabolic Disorders, 1998, 22(Suppl. 1):S3–S5.
51. Lobstein T. How much does obesity cost? The Food Magazine, 2004, 65.
52. Diet, nutrition and the prevention of chronic diseases. Report of a joint WHO/FAO expert
consultation. Geneva, World Health Organization, 2003 (WHO Technical Series, No. 916;
http://whqlibdoc.who.int/trs/WHO_TRS_916.pdf, accessed 25 May 2005).
53. Living longer in good health also a question of healthy lifestyle. Netherlands health-care
prevention policy. The Hague, Ministry of Health, Welfare and Sport, 2004 (International
Publication Series Health, Welfare and Sport, No. 19; http://www.minvws.nl/images/Living
%20longer%20in%20good%20health_tcm11-53021.pdf, accessed 25 May 2005).
54. National nutrition policy programme for Slovenia 2005–2010. Resolution approved by the
National Assembly of the Republic of Slovenia. Ljubljana, Ministry of Health of the Republic
of Slovenia, 2005.
55. Estrategia para la nutrición, actividad física y prevención de la obesidad [Strategy for
nutrition, physical activity and the prevention of obesity]. Madrid, Ministry of Health
and Consumer Affairs, 2005. (http://www.calidadalimentaria.com/uploads/noticias/
maqueta%20NAOS.pdf, accessed 25 May 2005).
56. Choosing health: making healthier choices easier. London, H.M. Government, 2004 (http://
www.dh.gov.uk/PublicationsAndStatistics/Publications/PublicationsPolicyAndGuidance/
PublicationsPolicyAndGuidanceArticle/fs/en?CONTENT_ID=4094550&chk=aN5Cor;
accessed 25 May 2005).
85
86
T H E E U R O P E A N H E A LT H R E P O R T 2 0 0 5
57. Campbell K et al. Interventions for preventing obesity in children. The Cochrane Database
of Systematic Reviews, 2002, 2:CD001871.
58. Spencer N. Poverty and child health, 2nd ed. Abingdon, Radcliffe Medical Press, 2000.
59. Lumley J et al. Peri-conceptual supplementation with folate and/or multivitamins for
preventing neural tube defects (Cochrane Review). The Cochrane Library, 2004, 1.
60. Protection, promotion and support of breastfeeding in Europe: a blueprint for action. Brussels,
European Commission, 2004 (http://europa.eu.int/comm/health/ph_projects/2002/
promotion/fp_promotion_2002_a3_18_en.pdf, accessed 25 May 2005).
61. Sikorski J et al. Support for breastfeeding mothers. The Cochrane Database of Systematic
Reviews, 2002, 1:CD001141.
62. International Code of Marketing of Breast-milk Substitutes. Geneva, World Health
Organization, 1981 (http://www.who.int/nut/documents/code_english.PDF, accessed 25
May 2005).
63. Jepson R. The effectiveness of interventions to change health related behaviours: a review of
reviews. Glasgow, MRC Social and Public Health Sciences Unit, 2000 (Occasional Paper
No. 3).
64. Strategic Framework for the Prevention of HIV Infection in Infants. Copenhagen, WHO
Regional Office for Europe, 2004 (http://www.euro.who.int/document/E84804.pdf,
accessed 25 May 2005).
65. Dublin Declaration on Partnership to Fight HIV/AIDS in Europe and Central Asia. Dublin,
Government of Ireland, 2004 (http://www.eu2004.ie/templates/meeting.asp?sNavlocator=5
,13&list_id=25, accessed 25 May 2005).
66. Valent F et al. Burden of disease attributable to selected environmental factors and injury
among children and adolescents in Europe. Lancet, 2004, 363(9426):2032–2039.
67. Health Evidence Network. How can injuries in children and older people be prevented?
Copenhagen, WHO Regional Office for Europe, 2004 (http://www.euro.who.int/eprise/
main/WHO/Progs/HEN/Syntheses/injuries/20041016_1; accessed 25 May 2005).
68. Children’s Environment and Health Action Plan for Europe. Copenhagen, WHO Regional
Office for Europe, 2004 (http://www.euro.who.int/document/e83338.pdf, accessed 25 May
2005).
69. Licari L, Nemer L, Tamburlini G. Children’s health and environment. Developing action
plans. Copenhagen, WHO Regional Office for Europe, 2005.
70. Currie C et al., eds. Young people’s health in context. Health Behaviour in School-aged
Children (HBSC) study: international report from the 2001/2002 survey. Copenhagen,
WHO Regional Office for Europe, 2004 (Health Policy for Children and Adolescents,
No. 4; http://www.euro.who.int/eprise/main/who/informationsources/publications/
catalogue/20040518_1, accessed 25 May 2005).
71. European Network of Health Promoting Schools [web site]. Copenhagen, WHO Regional
Office for Europe, 2004 (http://www.euro.who.int/eprise/main/WHO/Progs/ENHPS/
Home, accessed 25 May 2005).
REFERENCES
72. Gortmaker SL et al. Impact of school-based interdisciplinary interventions on diet and
physical activity among urban primary school children: eat well and keep moving. Archives
of Paediatrics and Adolescent Medicine, 1999, 153:975–983.
73. Health Evidence Network. What are the most effective strategies for reducing the rate of
teenage pregnancies? Copenhagen, WHO Regional Office for Europe, 2004 (http://www.
euro.who.int/hen/syntheses/short/20040423_6, accessed 25 May 2005).
74. Bannon M, Carter Y, eds. Protecting children from abuse and neglect in primary care. Oxford,
Oxford University Press, 2002.
75. Browne KD. Child protection. In: Rutter M, Taylor E, eds. Child and adolescent psychiatry:
modern approaches, 4th ed. London, Blackwell, 2002.
76. Browne KD et al. Early prediction and prevention of child abuse: a handbook. Chichester,
Wiley, 2002.
77. Report of the consultation on child abuse prevention. WHO, Geneva, 29–31 March 1999.
Geneva, World Health Organization, 1999 (http://whqlibdoc.who.int/hq/1999/WHO_
HSC_PVI_99.1.pdf, accessed 25 May 2005).
78. First Meeting on Strategies for Child Protection, Padua, Italy, 29–31 October 1998.
Copenhagen, WHO Regional Office for Europe, 1998 (http://www.euro.who.int/
Document/E63395.pdf, accessed 25 May 2005).
79. Krug EG et al., eds. World report on violence and health. Geneva, World Health
Organization, 2002 (http://whqlibdoc.who.int/hq/2002/9241545615.pdf, accessed 25 May
2005).
80. Improving maternal, infant and child health in the Russian Federation. Copenhagen, WHO
Regional Office for Europe, 2003.
81. Commission on Social Determinants of Health. Copenhagen, WHO Regional Office for
Europe, 2005 (http://www.euro.who.int/socialdeterminants/commision/20050705_1,
accessed 25 July 2005).
82. Bellamy C. The state of the world’s children 2005. New York, UNICEF, 2005 (http://www.
unicef.org/sowc05/english/sowc05.pdf, accessed 30May 2005).
83. UNICEF Innocenti Research Centre. Child poverty in rich countries 2005. Florence, United
Nations Children’s Fund (Report Card No. 6; http://www.unicef-icdc.org/publications/pdf/
repcard6e.pdf, accessed 25 May 2005).
84. Marmot M. Social determinants of health inequalities. Lancet, 2005, 365(9464):1099–1104.
85. Health Evidence Network. What are the main factors that influence the implementation
of disease prevention and health promotion programmes in children and adolescents?
Copenhagen, WHO Regional Office for Europe, 2005 (http://www.euro.who.int/eprise/
main/WHO/Progs/HEN/Syntheses/KeyElementsHP/20050615_10, accessed 22 June
2005).
86. Programme of Action for Children [web site]. Tullamore, The Health Boards Executive,
2004 (http://www.hebe.ie/ProgrammesProjects/ProgrammeofActionforChildren, accessed
25 May 2005).
87
88
T H E E U R O P E A N H E A LT H R E P O R T 2 0 0 5
87. Rigby M et al. The span in information from researching new tools to accessible
presentation – Experience from child and adolescent health. In: Kirch W, ed. Public
health in Europe – 10 Years of EUPHA. Berlin, Springer, 2003:275–292.
STATISTICAL
TABLES
90
T H E E U R O P E A N H E A LT H R E P O R T 2 0 0 5
Note on estimates of the burden of disease
in countries
Annex Tables 4 and 5 present the first country-specific estimates of the causes of the burden of
disease and attributable risk, in terms of both deaths and DALYs, for the WHO European Region.
Annex Table 7 presents burden of disease estimates in DALYs in children aged 0–14 years. These
estimates were produced in 2004, specifically for this report, by the Global Burden of Disease
project of the WHO Global Programme on Evidence for Health Policy.
The estimates of the burden of disease elaborate on previous results of the 2000 Global Burden
of Disease study (1) as published in the world health reports for 2003 and 2004 (2,3), and use the
most recent additional information available to WHO in 2004.
The estimates of attributable risk elaborate on the comparative risk assessment analyses carried
out for The world health report 2002 (4), but with updated country data on the burden from and
exposure to around four of the risk factors. Some changes were made in methods and results, in
general small ones, as compared to those of the 2002 report and published by Ezzati et al. (5).
These prior estimates should be interpreted as the best estimates of WHO, rather than the
official estimates of Member States. They have been computed using standard categories and
methods to ensure cross-national comparability, and may not be the same as official national
estimates produced using different but potentially equally rigorous methods. Documentation and
summary tables on the Global Burden of Disease study (6) are available, along with software tools
and a manual providing guidelines for conducting a national burden of disease study (7).
References
1. Mathers C et al. Global burden of disease in 2002: data sources, methods and results. Geneva,
World Health Organization, 2004 (http://www3.who.int/whosis/menu.cfm?path=evidence,bu
rden,burden_gbd2000docs,burden_gbd2000docs_DP54&language=english, accessed 27 April
2005).
2. The world health report 2003 – Shaping the future. Geneva, World Health Organization, 2003
(http://www.who.int/whr/2003/en, accessed 25 May 2005).
3. The world health report 2004 – Changing history. Geneva, World Health Organization, 2004
(http://www.who.int/whr/2004/en, accessed 27 April 2005).
4. The world health report 2002 – Reducing risks, promoting healthy life. Geneva, World Health
Organization, 2002 (http://www.who.int/whr/2002/en/, accessed 27 April 2005).
5. Ezzati M et al. Comparative quantification of health risks: global and regional burden of disease
attributable to selected major risk factors. Geneva, World Health Organization, 2004.
6. The Global Burden of Disease project: results for 2002 and earlier years, methods,
documentation and publications. Manuals, resources and software for carrying out national
burden of disease studies [web site]. Geneva, World Health Organization, 2005 (http://www.
who.int/evidence/bod, accessed 25 May 2005).
7. Mathers CD et al., eds. National burden of disease studies. A practical guide. Edition 2.0.
Geneva, World Health Organization, 2001 (http://www3.who.int/whosis/menu.cfm?path=evi
dence,burden,burden_manual&language=english, accessed 25 May 2005).
A N N E X TA B L E 1
91
Table 1. Population of the WHO European Region, 1990 to 2015 (projected)
Member State
Total population
(millions)
1990
Albania
Andorra
Armenia
Austria
Azerbaijan
Belarus
Belgium
Bosnia and Herzegovina
Bulgaria
Croatia
Cyprus
Czech Republic
Denmark
Estonia
Finland
France
Georgia
Germany
Greece
Hungary
Iceland
Ireland
Israel
Italy
Kazakhstan
Kyrgyzstan
Latvia
Lithuania
Luxembourg
Malta
Monaco
Netherlands
Norway
Poland
Portugal
Republic of Moldova
Romania
Russian Federation
San Marino
Serbia and Montenegro
Slovakia
Slovenia
Spain
Sweden
Switzerland
Tajikistan
TFYR Macedoniac
Turkey
Turkmenistan
Ukraine
United Kingdom
Uzbekistan
a
2003
2015
3.5
3.2
3.3
–
–
–
3.0
3.1
3.5
8.1
8.1
7.7
9.0
8.2
7.2
9.3
9.9
10.2
10.0 10.4 10.5
4.2
4.1
4.5
7.2
7.8
8.7
4.3
4.4
4.8
–
–
–
9.9
10.4 10.2
5.4
5.4
5.1
1.3
1.4
1.6
5.3
5.2
5.0
56.7 59.8 61.8
4.7
5.1
5.5
79.4 82.5 80.6
10.2 11.0 11.0
9.6
10.4 10.1
–
–
–
4.4
4.0
3.5
7.9
6.7
4.7
56.7 57.6 55.1
16.3 14.9 15.5
5.8
5.1
4.4
2.1
2.3
2.7
3.3
3.5
3.7
–
–
–
–
–
–
–
–
–
15.0 16.2 16.6
4.7
4.6
4.2
38.1 38.2 37.9
9.9 10.4 10.5
4.1
4.2
4.4
23.2 21.7 21.1
148.3 143.4 134.5
–
–
–
8.1 10.7
10.5a
5.3
5.4
5.3
2.0
2.0
2.0
38.8 41.1 41.5
9.0
9.0
8.6
7.6
7.4
6.7
7.2
6.3
5.3
2.2
2.0
1.9
56.2 70.7 81.2
5.7
4.9
3.7
51.9 48.4 44.7
57.6 59.3 60.0
20.5 25.6 30.1
Average annual
population growth
(%)
1990–2003
–0.3
–
–1.1
0.4
1.1
–0.2
0.3
–0.6
–0.8
–0.6
–
–0.1
0.4
–1.1
0.3
0.4
–0.5
0.3
0.6
–0.2
–
1.0
2.8
0.1
–0.7
1.0
–1.1
–0.5
–
–
–
0.6
0.6
0.0
0.4
–0.2
–0.5
–0.3
–
0.1b
0.2
0.0
0.4
0.3
0.7
1.3
0.6
1.8
2.2
–0.5
0.2
1.7
2003–2015
0.8
–
–0.1
0.0
0.7
–0.5
0.1
0.2
–0.7
–0.3
–
–0.2
0.1
–0.5
0.1
0.3
–0.7
–0.2
0.0
–0.5
–
0.8
1.4
–0.4
0.3
1.1
–0.7
–0.4
–
–
–
0.2
0.3
–0.1
0.0
–0.2
–0.3
–0.5
–
2.3
–0.1
–0.1
0.1
0.1
0.2
1.1
0.5
1.2
1.3
–0.7
0.1
1.3
Urban
population
(% of total)
Population
under age 15
(% of total)
Population aged
65 and above
(% of total)
2002
2015
2003
2015
2003
2015
43.2
91.9
64.6
65.8
50.2
70.5
97.2
43.9
69.4
58.6
69.0
74.2
85.2
69.4
61.0
76.1
52.2
87.9
60.6
64.7
92.7
59.6
91.6
67.3
55.8
34.0
66.3
66.8
91.6
91.4
100.0
65.4
77.6
61.8
54.1
45.9
54.5
73.3
88.8
51.8
57.2
50.8
76.4
83.3
67.6
25.0
59.4
65.8
45.1
67.2
89.0
36.8
51.2
91.1
64.2
67.2
51.3
75.2
97.5
51.1
74.0
64.6
71.6
75.7
86.8
71.4
62.1
79.0
51.6
90.0
65.2
70.0
94.1
63.6
92.4
69.2
58.2
35.4
66.3
67.5
94.1
93.7
100.0
71.4
86.4
64.0
60.9
50.0
56.4
74.3
89.1
55.5
60.8
52.6
78.1
84.3
68.7
24.4
62.0
71.9
50.0
68.9
90.2
37.0
27.3
–
20.5
16.2
27.0
16.8
17.0
17.2
14.4
16.2
–
15.5
18.6
16.1
17.6
18.6
18.4
14.9
14.7
16.3
–
21.3
27.4
14.0
24.5
31.7
15.1
17.7
–
–
–
18.3
19.7
17.6
17.3
20.4
16.6
16.3
–
19.6
18.2
15.0
15.0
17.5
16.6
36.5
21.5
28.3
33.8
16.0
18.2
33.3
2.9
–
14.4
12.4
23.5
14.1
15.5
14.1
12.6
16.5
18.9
13.2
16.3
14.2
15.8
17.8
15.2
13.2
13.2
13.3
18.7
20.3
24.8
12.3
21.4
26.4
13.0
16.0
17.6
17.0
–
16.4
16.6
14.6
15.3
16.5
15.4
13.7
–
16.9
15.4
12.1
13.2
15.7
12.6
28.5
20.0
25.0
27.4
13.2
15.9
26.2
7.3
–
10.2
16.0
7.5
14.0
16.8
10.9
16.4
15.8
–
13.9
14.9
15.2
15.3
16.1
14.3
17.3
18.7
14.7
–
11.2
9.7
19.0
8.1
6.1
15.5
14.2
–
–
–
14.0
14.9
12.5
15.2
11.1
13.9
13.2
–
14.0
11.4
14.6
17.1
17.5
15.6
4.6
10.7
5.9
4.5
15.1
16.0
4.9
0.1
–
9.9
19.5
5.9
14.3
19.5
13.6
18.0
17.8
14.9
18.6
19.2
18.2
20.3
18.5
14.9
20.8
20.9
17.4
13.5
13.4
11.4
22.3
8.4
5.9
18.3
16.4
14.4
18.0
–
17.4
18.0
14.8
18.0
10.9
14.8
14.3
–
14.9
13.6
18.5
19.2
21.4
22.0
4.6
12.2
6.7
4.6
16.1
17.8
5.0
Total
fertility
rate,
2000–
2005
Includes population of Kosovo until 2001.
Data are for 1990 to 2001.
The former Yugoslav Republic of Macedonia.
Sources: World development indicators 2005. Washington, DC, World Bank, 2005 (http://www.worldbank.org/data/wdi2005/; accessed 25 May 2005), and Human development
report 2004. Cultural liberty in today’s diverse world. New York, United Nations Development Programme (http://hdr.undp.org/reports/global/2004/; accessed 25 May 2005).
b
c
2.3
–
1.2
1.3
2.1
1.2
1.7
1.3
1.1
1.7
1.9
1.2
1.8
1.2
1.7
1.9
1.4
1.4
1.3
1.2
2.0
1.9
2.7
1.2
2.0
2.6
1.1
1.3
1.7
1.8
–
1.7
1.8
1.3
1.5
1.4
1.3
1.1
–
1.7
1.3
1.1
1.2
1.6
1.4
3.1
1.9
2.4
2.7
1.2
1.6
2.4
92
T H E E U R O P E A N H E A LT H R E P O R T 2 0 0 5
Table 2. Basic public health indicators in the WHO European Region
Health expenditure, immunization and ill health
Member State
Total health
expenditure, 2002
% of
GDP
Albania
Andorra
Armenia
Austria
Azerbaijan
Belarus
Belgium
Bosnia and Herzegovina
Bulgaria
Croatia
Cyprus
Czech Republic
Denmark
Estonia
Finland
France
Georgia
Germany
Greece
Hungary
Iceland
Ireland
Israel
Italy
Kazakhstan
Kyrgyzstan
Latvia
Lithuania
Luxembourg
Malta
Monaco
Netherlands
Norway
Poland
Portugal
Republic of Moldova
Romania
Russian Federation
San Marino
Serbia and Montenegro
Slovakia
Slovenia
Spain
Sweden
Switzerland
Tajikistan
TFYR Macedoniac
Turkey
Turkmenistan
Ukraine
United Kingdom
Uzbekistan
a
b
c
6.1
6.5
5.8
7.7
3.7
6.4
9.1
9.2
7.4
7.3
7.0
7.0
8.8
5.1
7.3
9.7
3.8
10.9
9.5
7.8
9.9
7.3
9.1
8.5
3.5
4.3
5.1
5.9
6.2
9.7
11.0
8.8
9.6
6.1
9.3
7.0
6.3
6.2
7.7
8.1
5.9
8.3
7.6
9.2
11.2
3.3
6.8
6.5
4.3
4.7
7.7
5.5
2002.
2001.
The former Yugoslav Republic of Macedonia.
Per head
(international
dollar rate)
302
1908
232
2220
120
583
2515
322
499
630
883
1118
2583
604
1943
2736
123
2817
1814
1078
2802
2367
1890
2166
261
117
477
549
3066
965
4258
2564
3409
657
1702
151
469
535
3094
305
723
1547
1640
2512
3446
47
341
420
182
210
2160
143
General government
health expenditure, 2002
% of total
expenditure
on health
39
71
23
70
22
74
71
50
53
81
41
91
83
76
76
76
27
79
53
70
84
75
66
76
53
51
64
73
85
72
80
66
84
72
71
58
66
56
79
63
89
75
71
85
58
28
85
66
71
71
83
46
% of total
government
expenditure
8
27
6
11
3
11
13
9
10
12
7
15
13
11
11
14
6
18
11
10
18
16
11
13
9
10
9
14
12
14
15
12
18
10
14
13
13
10
20
11
10
15
14
14
19
6
14
10
12
9
16
7
One-year-olds
immunized (%), 2003
With
DTP3
97
99
94
84
97
86
90
87
96
94
98
97
96
94
98
97
76
89
88
99
97
85
97
96
99
98
98
94
98
94
99
98
90
99
99
98
97
98
96
89
99
92
98
98
95
82
96
68
98
97
91
98
TB under
DOTS
Against
measles
Cases
detected
(%), 2003
Treatment
success
(%), 2002
93
96
94
79
98
99
75
84
96
95
86
99
96
95
97
86
73
92
88
99
93
78
95
83
99
99
99
98
91
90
99
96
84
97
96
96
97
96
91
87
99
94
97
94
82
89
96
75
97
99
80
99
28
75
58
87a
25
98
73
76
90
0
102
92
88
85
0
0
99
97
0
88
63
0
83
101
120
97
97
108
98
26
–
102
128
81
86
55
45
13
58
51
69
75
0
98
0
8
75
–
56
0
0
34
90
100
79
64b
84
–
69
95
86
–
75
73
77
67
–
–
65
69
–
55
100
–
80
79
78
82
76
72
–
60
–
68
80
86
82
61
76
67
0
91
84
85
–
73
–
78
79
–
77
–
–
80
A N N E X TA B L E 2
93
Life expectancy and mortality
Stunting
in children
under 5
(%),
1997–2003
Low birth
weight
(%),
2000–2002
Life expectancy at
birth (years), 2003
Adult mortality rate (per 1000
population aged 15–60 years), 2003
Males
Females
Males
35.1
–
12.9
–
13.3
–
–
9.7
–
–
–
–
–
–
–
–
11.7
–
–
–
–
–
–
–
9.7
24.8
–
–
–
–
–
–
–
–
–
–
10.1
–
–
5.1
–
–
–
–
–
36.2
6.9
16
22.3
15.9
–
21.1
3
–
7
7
11
5
8
4
10
6
–
7
5
4
4
7
6
7
8
9
4
6
8
6
8
7
5
4
8
6
–
–
5
6
8
5
9
6
–
4
7
6
6
4
6
15
5
16
6
5
8
7
69
78
65
76
62
63
75
69
69
71
76
72
75
65
75
76
67
76
76
68
78
76
78
78
56
59
66
66
76
76
78
76
77
71
74
63
68
58
78
70
70
73
76
78
78
59
69
68
56
62
76
63
75
84
72
82
68
75
82
76
76
78
81
79
80
77
82
84
75
82
81
77
82
81
82
84
67
68
76
78
82
81
85
81
82
79
81
71
75
72
84
75
78
81
83
83
83
63
75
73
65
73
81
69
167
107
240
115
220
370
125
190
216
173
99
166
121
319
134
132
195
115
118
257
81
100
92
93
419
339
306
302
115
84
110
93
96
202
150
303
239
480
73
186
204
165
116
79
90
225
202
176
352
384
103
226
Females
92
41
108
59
120
130
66
89
91
70
47
74
73
114
57
59
76
59
48
111
53
60
51
47
187
160
120
106
63
49
47
66
58
81
63
152
107
182
32
99
77
69
46
50
50
169
86
111
171
142
64
142
Under-5 mortality rate
(per 1000 live births)
Under 5
years, 2003
21
5
33
6
91
10
5
17
15
7
6
5
5
8
4
5
45
5
6
9
3
6
6
5
73
68
13
9
4
6
4
6
4
8
6
32
20
16
4
14
8
5
5
4
5
118
12
39
102
20
6
69
Before 28
days, 2000
12
4
17
3
36
5
3
11
8
5
4
2
4
6
2
3
25
3
4
6
2
4
4
3
32
31
7
5
4
5
3
4
3
6
3
16
9
9
2
9
5
4
3
2
3
38
9
22
35
9
4
27
Maternal mortality rate
(per 100 000 live births)
WHO estimate, Reported,
2000
1995–2003
55
–
55
5
94
36
10
31
32
10
47
9
7
38
5
17
32
9
10
11
0
4
13
5
210
110
61
19
28
–
–
16
10
10
8
36
58
65
–
9
10
17
5
8
7
100
13
70
31
38
11
24
Coverage of
registration
of deaths (%),
2003 or latest
available year
20
–
34
3
29
20
7
–
16
13
7
7
12
19
5
9
51
5
4
7
15
4
5
3
54
51
22
13
11
15
–
8
6
5
6
30
32
37
–
7
8
14
4
4
5
42
10
–
–
23
5
33
Note. WHO computed the figures to ensure comparability; they are not necessarily the official statistics of Member States, which may use alternative rigorous methods.
Sources: The world health report 2005 – Make every mother and child count. Geneva, World Health Organization, 2005 (http://www.who.int/whr/2005/en, accessed 25 May
2005) and World health statistics 2005. Geneva, World Health Organization, 2005 (http://www3.who.int/statistics/, accessed 30 May 2005).
94
46
78
100
72
98
100
88
100
99
83
100
100
100
100
100
64
100
90
100
91
98
100
98
79
71
100
100
100
100
–
100
98
100
100
83
100
97
>75
90
100
100
100
100
100
50
90
43
76
99
100
80
94
T H E E U R O P E A N H E A LT H R E P O R T 2 0 0 5
Table 3. Level and distribution of income in the WHO European Region
Member State
Albania
Andorra
Armenia
Austria
Azerbaijan
Belarus
Belgium
Bosnia and Herzegovina
Bulgaria
Croatia
Cyprus
Czech Republic
Denmark
Estonia
Finland
France
Georgia
Germany
Greece
Hungary
Iceland
Ireland
Israel
Italy
Kazakhstan
Kyrgyzstan
Latvia
Lithuania
Luxembourg
Malta
Monaco
Netherlands
Norway
Poland
Portugal
Republic of Moldova
Romania
Russian Federation
San Marino
Serbia and Montenegro
Slovakia
Slovenia
Spain
Sweden
Switzerland
Tajikistan
TFYR Macedoniaa
Turkey
Turkmenistan
Ukraine
United Kingdom
Uzbekistan
a
GDP
per head
(US$ PPP),
2002
4 830
–
3 120
29 220
3 210
5 520
27 570
–
7 130
10 240
18 150
15 780
30 940
12 260
26 190
26 920
2 260
27 100
18 720
13 400
29 750
36 360
19 530
26 430
5 870
1 620
9 210
10 320
61 190
17 640
–
29 100
36 600
10 560
18 280
1 470
6 560
8 230
–
–
12 840
18 540
21 460
26 050
30 010
980
6 470
6 390
4 250
4 870
26 150
1 670
Average annual
growth of GDP (%)
1980–1990
1.5
–
–
2.3
–
–
2.1
–
3.4
–
–
–
2.0
2.2
3.3
2.4
0.4
2.3
0.9
1.3
–
3.2
3.5
2.5
–
–
3.2
–
–
–
–
2.4
3.0
–
3.2
2.8
1.3
–
–
–
2.0
–
3.1
2.5
2.0
2.0
–
5.3
–
–
3.2
–
1990–2003
4.6
–
1.5
2.1
–1.5
0.6
2.1
–
–0.2
1.7
–
1.4
2.3
2.1
2.8
1.9
–3.1
1.5
2.7
2.4
–
7.7
4.3
1.6
–0.6
–1.4
1.0
–0.1
–
–
–
2.7
3.5
4.2
2.6
–5.9
0.1
–1.8
–
1.4
2.5
3.1
2.8
2.3
1.2
–5.3
–0.1
3.1
0.9
–5.3
2.7
1.2
Share of income
or consumption (%)
Poorest
10%
3.8
–
2.6
3.1
3.1
3.5
2.9
3.9
2.4
3.4
–
4.3
2.6
1.9
4.0
2.8
2.3
3.2
2.9
4.0
–
2.8
2.4
2.3
3.2
3.2
2.8
3.2
3.5
–
–
2.5
3.9
3.1
2.0
2.7
3.2
3.3
–
–
3.1
3.6
2.8
3.6
2.6
3.3
3.3
2.3
2.6
3.7
2.1
3.6
Poorest
20%
9.1
–
6.7
8.1
7.4
8.4
8.3
9.5
6.7
8.3
–
10.3
8.3
6.1
9.6
7.2
6.4
8.5
7.1
9.5
–
7.1
6.9
6.5
7.8
7.7
7.3
7.9
8.4
–
–
7.6
9.6
7.6
5.8
6.8
7.9
8.2
–
–
8.8
9.1
7.5
9.1
6.9
7.9
8.4
6.1
6.1
8.8
6.1
9.2
Inequality measures
Richest
20%
Richest
10%
37.4
–
45.1
38.5
44.5
39.1
37.3
35.8
38.9
39.6
–
35.9
35.8
44.0
36.7
40.2
43.6
36.9
43.6
36.5
–
43.3
44.3
42.0
40.0
43.0
41.1
40.0
38.9
–
–
38.7
37.2
41.9
45.9
44.1
41.o
39.3
–
–
34.8
35.7
40.3
36.6
40.3
40.8
36.7
46.7
47.5
37.8
44.0
36.3
22.4
–
29.7
23.5
29.5
24.1
22.6
21.4
23.7
24.5
–
22.4
21.3
28.5
22.6
25.1
27.9
22.1
28.5
22.2
–
27.6
28.2
26.8
24.4
27.9
26.1
24.9
23.8
–
–
22.9
23.4
26.7
29.8
28.4
26.1
23.8
–
–
20.9
21.4
25.2
22.2
25.2
25.6
22.1
30.7
31.7
23.2
28.5
22.0
Ratio of income or
consumption share
of richest 10% to
poorest 10%
5.9
–
11.5
7.6
9.7
6.9
7.8
5.4
9.9
7.3
–
5.2
8.1
14.9
5.6
9.1
12.0
6.9
10.0
5.6
–
9.7
11.7
11.6
7.6
8.7
9.3
7.9
6.8
–
–
9.2
6.1
8.6
15.0
10.5
8.2
7.2
–
–
6.7
5.9
9.0
6.2
9.9
7.8
6.8
13.3
12.3
6.4
13.8
6.1
The former Yugoslav Republic of Macedonia.
Note. WHO computed the figures to ensure comparability; they are not necessarily the official statistics of Member States, which may use alternative rigorous methods.
Sources: World development indicators 2005. Washington, DC, World Bank, 2005 (http://www.worldbank.org/data/wdi2005/; accessed 2 May 2005) and Human development
report 2004. Cultural liberty in today’s diverse world. New York, United Nations Development Programme (http://hdr.undp.org/reports/global/2004/; accessed 2 May 2005).
Gini
index
28.2
–
37.9
30.0
36.5
30.4
25.0
26.2
31.9
29.0
–
25.4
24.7
37.2
26.9
32.7
36.9
28.3
35.4
26.9
–
35.9
35.5
36.0
32.3
34.8
33.6
31.9
30.8
–
–
30.9
25.8
34.1
38.5
36.9
30.3
31.0
–
–
25.8
28.4
32.5
25.0
33.1
32.6
28.2
40.0
40.8
29.0
36.0
26.8
A N N E X TA B L E 4
95
Table 4. Deaths and DALYs attributable to the 10 leading causes in the WHO European Region, 2002
Mortality
Causes
ALBANIA
% of
total
All causes
1. Cerebrovascular disease
2. Ischaemic heart disease
3. Lower respiratory infections
4. Trachea, bronchus and lung cancer
5. Stomach cancer
6. Liver cancer
7. Perinatal conditions
8. Hypertensive heart disease
9. Nephritis and nephrosis
10. Chronic obstructive pulmonary disease
22 096
4 169
3 989
973
933
572
552
540
444
369
275
100.0
18.9
18.1
4.4
4.2
2.6
2.5
2.4
2.0
1.7
1.2
All causes
1. Unipolar depressive disorders
2. Ischaemic heart disease
3. Cerebrovascular disease
4. Perinatal conditions
5. Lower respiratory infections
6. Osteoarthritis
7. Falls
8. Iodine deficiency
9. Hearing loss, adult onset
10. Trachea, bronchus and lung cancer
ANDORRA
Total
deaths
All causes
1. Ischaemic heart disease
2. Cerebrovascular disease
3. Alzheimer’s and other dementias
4. Trachea, bronchus and lung cancer
5. Chronic obstructive pulmonary disease
6. Colon and rectum cancer
7. Diabetes mellitus
8. Lower respiratory infections
9. Breast cancer
10. Road-traffic accidents
562
67
52
35
30
25
22
14
13
11
10
100.0
12.0
9.3
6.2
5.3
4.5
3.9
2.5
2.3
2.0
1.9
All causes
1. Unipolar depressive disorders
2. Alcohol-use disorders
3. Alzheimer’s and other dementias
4. Ischaemic heart disease
5. Cerebrovascular disease
6. Hearing loss, adult onset
7. Chronic obstructive pulmonary disease
8. Road-traffic accidents
9. Trachea, bronchus and lung cancer
10. Diabetes mellitus
ARMENIA
Causes
DALYs
All causes
1. Ischaemic heart disease
2. Cerebrovascular disease
3. Diabetes mellitus
4. Trachea, bronchus and lung cancer
5. Chronic obstructive pulmonary disease
6. Inflammatory heart diseases
7. Hypertensive heart disease
8. Breast cancer
9. Stomach cancer
10. Cirrhosis of the liver
26 148
8 515
4 212
1 559
998
782
580
511
504
502
496
AUSTRIA
Member
State
All causes
1. Ischaemic heart disease
2. Cerebrovascular disease
3. Trachea, bronchus and lung cancer
4. Colon and rectum cancer
5. Chronic obstructive pulmonary disease
6. Cirrhosis of the liver
7. Breast cancer
8. Self-inflicted injuries
9. Diabetes mellitus
10. Hypertensive heart disease
70 450
15 418
7 559
3 170
2 531
2 122
1 758
1 633
1 476
1 428
1 247
Total
DALYs
% of
total
502 753
36 939
35 959
33 238
21 520
18 911
12 258
10 198
9 376
9 087
8 828
100.0
7.3
7.2
6.6
4.3
3.8
2.4
2.0
1.9
1.8
1.8
8 546
715
449
378
369
342
303
286
276
250
224
100.0
8.4
5.3
4.4
4.3
4.0
3.6
3.3
3.2
2.9
2.6
100.0
32.6
16.1
6.0
3.8
3.0
2.2
2.0
1.9
1.9
1.9
All causes
516 208
1. Ischaemic heart disease
65 285
2. Unipolar depressive disorders
38 243
3. Cerebrovascular disease
34 430
4. Perinatal conditions
20 268
5. Diabetes mellitus
18 936
6. Hearing loss, adult onset
15 853
7. Congenital anomalies
14 392
8. Vision disorders, age-related
11 688
9. Trachea, bronchus and lung cancer
10 070
10. Chronic obstructive pulmonary disease
8 920
100.0
12.6
7.4
6.7
3.9
3.7
3.1
2.8
2.3
2.0
1.7
100.0
21.9
10.7
4.5
3.6
3.0
2.5
2.3
2.1
2.0
1.8
All causes
969 681
1. Unipolar depressive disorders
95 118
2. Ischaemic heart disease
79 989
3. Cerebrovascular disease
49 230
4. Alcohol-use disorders
48 850
5. Hearing loss, adult onset
36 543
6. Alzheimer’s and other dementias
34 102
7. Chronic obstructive pulmonary disease
30 652
8. Trachea, bronchus and lung cancer
26 882
9. Self-inflicted injuries
26 204
10. Cirrhosis of the liver
95 118
100.0
9.8
8.2
5.1
5.0
3.8
3.5
3.2
2.8
2.7
9.8
Source: data from Mathers C et al. Global burden of disease in 2002: data sources, methods and results. Geneva, World Health Organization, 2004 (http://www3.
who.int/whosis/menu.cfm?path=evidence,burden,burden_gbd2000docs,burden_gbd2000docs_DP54&language=english, accessed 25 May 2005).
96
T H E E U R O P E A N H E A LT H R E P O R T 2 0 0 5
Table 4 contd
Mortality
Causes
Total
DALYs
% of
total
AZERBAIJAN
% of
total
All causes
1. Ischaemic heart disease
2. Lower respiratory infections
3. Unipolar depressive disorders
4. Perinatal conditions
5. Cerebrovascular disease
6. Diarrhoeal diseases
7. Tuberculosis
8. Hearing loss, adult onset
9. Anaemia
10. Diabetes mellitus
64 213
22 302
6 540
5 260
2 212
1 666
1 648
1 532
1 485
1 464
1 343
100.0
34.7
10.2
8.2
3.4
2.6
2.6
2.4
2.3
2.3
2.1
All causes
1. Ischaemic heart disease
2. Lower respiratory infections
3. Unipolar depressive disorders
4. Perinatal conditions
5. Cerebrovascular disease
6. Diarrhoeal diseases
7. Tuberculosis
8. Hearing loss, adult onset
9. Anaemia
10. Diabetes mellitus
1 545 013
180 052
156 395
99 044
68 795
60 065
36 545
36 406
35 630
35 164
34 711
100.0
11.7
10.1
6.4
4.5
3.9
2.4
2.4
2.3
2.3
2.2
BELARUS
Total
deaths
All causes
143 574
1. Ischaemic heart disease
59 423
2. Cerebrovascular disease
22 790
3. Chronic obstructive pulmonary disease
5 192
4. Poisonings
3 956
5. Self-inflicted injuries
3 796
6. Trachea, bronchus and lung cancer
3 707
7. Stomach cancer
3 146
8. Colon and rectum cancer
2 550
9. HIV/AIDS
2 201
10. Drownings
1 712
100.0
41.4
15.9
3.6
2.8
2.6
2.6
2.2
1.8
1.5
1.2
All causes
2 192 251
1. Ischaemic heart disease
382 458
2. Cerebrovascular disease
188 174
3. Unipolar depressive disorders
107 552
4. Self-inflicted injuries
78 206
5. Poisonings
75 063
6. Alcohol-use disorders
63 271
7. Chronic obstructive pulmonary disease
62 291
8. HIV/AIDS
55 818
9. Road-traffic accidents
52 635
10. Hearing loss, adult onset
52 491
100.0
17.4
8.6
4.9
3.6
3.4
2.9
2.8
2.5
2.4
2.4
BELGIUM
Causes
DALYs
All causes
102 947
1. Ischaemic heart disease
14 985
2. Cerebrovascular disease
9 234
3. Trachea, bronchus and lung cancer
7 191
4. Lower respiratory infections
5 043
5. Chronic obstructive pulmonary disease
4 989
6. Alzheimer’s and other dementias
4 193
7. Colon and rectum cancer
3 471
8. Breast cancer
2 586
9. Self-inflicted injuries
2 148
10. Prostate cancer
2 104
100.0
14.6
9.0
7.0
4.9
4.8
4.1
3.4
2.5
2.1
2.0
All causes
1 357 930
1. Unipolar depressive disorders
131 685
2. Ischaemic heart disease
88 271
3. Chronic obstructive pulmonary disease
66 096
4. Cerebrovascular disease
62 978
5. Alzheimer’s and other dementias
56 459
6. Trachea, bronchus and lung cancer
55 114
7. Alcohol-use disorders
47 778
8. Hearing loss, adult onset
46 041
9. Self-inflicted injuries
42 090
10. Road-traffic accidents
36 582
100.0
9.7
6.5
4.9
4.6
4.2
4.1
3.5
3.4
3.1
2.7
BOSNIA AND HERZEGOVINA
Member
State
All causes
1. Cerebrovascular disease
2. Ischaemic heart disease
3. Inflammatory heart diseases
4. Trachea, bronchus and lung cancer
5. Diabetes mellitus
6. Colon and rectum cancer
7. Self-inflicted injuries
8. Liver cancer
9. Nephritis and nephrosis
10. Cirrhosis of the liver
100.0
18.7
16.0
9.8
4.6
1.9
1.7
1.6
1.6
1.5
1.5
All causes
1. Cerebrovascular disease
2. Unipolar depressive disorders
3. Ischaemic heart disease
4. Inflammatory heart diseases
5. Osteoarthritis
6. Trachea, bronchus and lung cancer
7. Perinatal conditions
8. Hearing loss, adult onset
9. Self-inflicted injuries
10. Vision disorders, age-related
100.0
9.7
7.9
7.8
4.0
3.1
2.7
2.6
2.4
2.0
2.0
34 894
6 508
5 590
3 404
1 618
646
587
572
545
519
517
649 408
63 065
51 184
50 385
26 265
20 224
17 241
16 876
15 671
12 971
12 927
A N N E X TA B L E 4
Mortality
Causes
Total
DALYs
% of
total
BULGARIA
% of
total
All causes
1. Ischaemic heart disease
2. Cerebrovascular disease
3. Hypertensive heart disease
4. Trachea, bronchus and lung cancer
5. Colon and rectum cancer
6. Diabetes mellitus
7. Stomach cancer
8. Lower respiratory infections
9. Cirrhosis of the liver
10. Self-inflicted injuries
106 748
26 638
21 508
4 709
3 052
2 323
1 972
1 783
1 566
1 494
1 347
100.0
25.0
20.1
4.4
2.9
2.2
1.8
1.7
1.5
1.4
1.3
All causes
1. Ischaemic heart disease
2. Cerebrovascular disease
3. Unipolar depressive disorders
4. Osteoarthritis
5. Diabetes mellitus
6. Hearing loss, adult onset
7. Alcohol-use disorders
8. Hypertensive heart disease
9. Vision disorders, age-related
10. Trachea, bronchus and lung cancer
1 464 368
179 532
164 980
94 865
40 511
36 538
33 172
32 527
32 470
32 027
31 686
100.0
12.3
11.3
6.5
2.8
2.5
2.3
2.2
2.2
2.2
2.2
CROATIA
Total
deaths
All causes
1. Ischaemic heart disease
2. Cerebrovascular disease
3. Trachea, bronchus and lung cancer
4. Colon and rectum cancer
5. Cirrhosis of the liver
6. Stomach cancer
7. Breast cancer
8. Self-inflicted injuries
9. Lower respiratory infections
10. Hypertensive heart disease
50 446
11 653
8 653
2 729
1 620
1 392
1 045
957
885
869
865
100.0
23.1
17.2
5.4
3.2
2.8
2.1
1.9
1.8
1.7
1.7
All causes
709 409
1. Cerebrovascular disease
77 915
2. Ischaemic heart disease
73 783
3. Unipolar depressive disorders
52 908
4. Alcohol-use disorders
33 345
5. Trachea, bronchus and lung cancer
24 818
6. Hearing loss, adult onset
19 980
7. Cirrhosis of the liver
19 749
8. Alzheimer’s and other dementias
18 178
9. Road-traffic accidents
15 660
10. Chronic obstructive pulmonary disease
15 405
100.0
11.0
10.4
7.5
4.7
3.5
2.8
2.8
2.6
2.2
2.2
CYPRUS
Causes
DALYs
All causes
1. Ischaemic heart disease
2. Cerebrovascular disease
3. Lower respiratory infections
4. Road-traffic accidents
5. Trachea, bronchus and lung cancer
6. Breast cancer
7. Colon and rectum cancer
8. Nephritis and nephrosis
9. Bladder cancer
10. Stomach cancer
7 494
1 358
795
497
214
182
126
107
99
76
74
100.0
18.1
10.6
6.6
2.9
2.4
1.7
1.4
1.3
1.0
1.0
All causes
1. Unipolar depressive disorders
2. Ischaemic heart disease
3. Vision disorders, age-related
4. Road-traffic accidents
5. Hearing loss, adult onset
6. Cataracts
7. Diabetes mellitus
8. Cerebrovascular disease
9. Lower respiratory infections
10. Schizophrenia
108 491
7 476
7 400
7 224
5 931
5 480
4 536
4 283
3 609
2 936
2 017
100.0
6.9
6.8
6.7
5.5
5.1
4.2
3.9
3.3
2.7
1.9
CZECH REPUBLIC
Member
State
97
All causes
103 313
1. Ischaemic heart disease
25 899
2. Cerebrovascular disease
15 663
3. Trachea, bronchus and lung cancer
5 736
4. Colon and rectum cancer
4 607
5. Lower respiratory infections
2 291
6. Breast cancer
1 931
7. Cirrhosis of the liver
1 812
8. Chronic obstructive pulmonary disease
1 774
9. Falls
1 758
10. Self-inflicted injuries
1 665
100.0
25.1
15.2
5.6
4.5
2.2
1.9
1.8
1.7
1.7
1.6
All causes
1 474 275
1. Ischaemic heart disease
163 488
2. Cerebrovascular disease
115 113
3. Unipolar depressive disorders
104 052
4. Alcohol-use disorders
63 520
5. Trachea, bronchus and lung cancer
51 746
6. Hearing loss, adult onset
44 139
7. Colon and rectum cancer
40 399
8. Alzheimer’s and other dementias
38 864
9. Chronic obstructive pulmonary disease
36 750
10. Self-inflicted injuries
31 758
100.0
11.1
7.8
7.1
4.3
3.5
3.0
2.7
2.6
2.5
2.2
98
T H E E U R O P E A N H E A LT H R E P O R T 2 0 0 5
Table 4 contd
Mortality
Causes
Total
DALYs
% of
total
DENMARK
% of
total
All causes
1. Ischaemic heart disease
2. Cerebrovascular disease
3. Chronic obstructive pulmonary disease
4. Trachea, bronchus and lung cancer
5. Colon and rectum cancer
6. Falls
7. Alzheimer’s and other dementias
8. Breast cancer
9. Diabetes mellitus
10. Lower respiratory infections
57 418
10 013
4 871
4 039
3 380
2 480
1 637
1 591
1 496
1 493
1 476
100.0
17.4
8.5
7.0
5.9
4.3
2.9
2.8
2.6
2.6
2.6
All causes
750 197
1. Unipolar depressive disorders
61 059
2. Chronic obstructive pulmonary disease
57 489
3. Ischaemic heart disease
46 019
4. Cerebrovascular disease
35 294
5. Alcohol-use disorders
35 276
6. Trachea, bronchus and lung cancer
25 904
7. Alzheimer’s and other dementias
25 119
8. Hearing loss, adult onset
23 447
9. Colon and rectum cancer
17 723
10. Diabetes mellitus
15 452
100.0
8.1
7.7
6.1
4.7
4.7
3.5
3.3
3.1
2.4
2.1
ESTONIA
Total
deaths
All causes
1. Ischaemic heart disease
2. Cerebrovascular disease
3. Trachea, bronchus and lung cancer
4. Poisonings
5. Self-inflicted injuries
6. Colon and rectum cancer
7. Hypertensive heart disease
8. Stomach cancer
9. Lower respiratory infections
10. Inflammatory heart diseases
18 246
6 235
2 964
664
431
384
381
350
340
334
313
100.0
34.2
16.2
3.6
2.4
2.1
2.1
1.9
1.9
1.8
1.7
All causes
1. Ischaemic heart disease
2. Cerebrovascular disease
3. Unipolar depressive disorders
4. Poisonings
5. Alcohol-use disorders
6. Self-inflicted injuries
7. Hearing loss, adult onset
8. Road-traffic accidents
9. Violence
10. Osteoarthritis
264 152
33 180
18 850
14 195
8 267
7 918
7 639
7 338
6 612
6 302
6 175
100.0
12.6
7.1
5.4
3.1
3.0
2.9
2.8
2.5
2.4
2.3
FINLAND
Causes
DALYs
All causes
1. Ischaemic heart disease
2. Cerebrovascular disease
3. Alzheimer’s and other dementias
4. Lower respiratory infections
5. Trachea, bronchus and lung cancer
6. Self-inflicted injuries
7. Chronic obstructive pulmonary disease
8. Colon and rectum cancer
9. Falls
10. Breast cancer
48 461
12 488
4 875
3 682
2 375
1 934
1 215
1 095
1 073
1 055
933
100.0
25.7
10.0
7.6
4.9
4.0
2.5
2.3
2.2
2.2
1.9
All causes
667 725
1. Unipolar depressive disorders
72 348
2. Ischaemic heart disease
62 918
3. Cerebrovascular disease
35 795
4. Alzheimer’s and other dementias
30 261
5. Alcohol-use disorders
26 466
6. Self-inflicted injuries
25 330
7. Hearing loss, adult onset
22 888
8. Osteoarthritis
14 899
9. Trachea, bronchus and lung cancer
13 986
10. Chronic obstructive pulmonary disease
13 976
100.0
10.8
9.4
5.4
4.5
4.0
3.8
3.4
2.2
2.1
2.1
FRANCE
Member
State
All causes
499 040
1. Ischaemic heart disease
45 501
2. Cerebrovascular disease
37 246
3. Trachea, bronchus and lung cancer
26 069
4. Lower respiratory infections
19 404
5. Colon and rectum cancer
17 499
6. Alzheimer’s and other dementias
16 739
7. Chronic obstructive pulmonary disease
16 138
8. Breast cancer
12 535
9. Diabetes mellitus
11 378
10. Falls
10 055
100.0
9.1
7.5
5.2
3.9
3.5
3.4
3.2
2.5
2.3
2.0
All causes
7 406 472
1. Unipolar depressive disorders
761 929
2. Alcohol-use disorders
398 770
3. Alzheimer’s and other dementias
288 825
4. Cerebrovascular disease
259 266
5. Hearing loss, adult onset
253 702
6. Ischaemic heart disease
248 323
7. Road-traffic accidents
245 691
8. Trachea, bronchus and lung cancer
243 306
9. Chronic obstructive pulmonary disease 205 199
10. Self-inflicted injuries
174 870
100.0
10.3
5.4
3.9
3.5
3.4
3.4
3.3
3.3
2.8
2.4
A N N E X TA B L E 4
Mortality
Causes
Total
DALYs
% of
total
GEORGIA
% of
total
All causes
1. Ischaemic heart disease
2. Cerebrovascular disease
3. Cirrhosis of the liver
4. Diabetes mellitus
5. Trachea, bronchus and lung cancer
6. Perinatal conditions
7. Breast cancer
8. Lower respiratory infections
9. Stomach cancer
10. Tuberculosis
61 349
26 035
15 680
1 641
1 202
1 193
950
879
872
828
729
100.0
42.4
25.6
2.7
2.0
1.9
1.5
1.4
1.4
1.3
1.2
All causes
1. Ischaemic heart disease
2. Cerebrovascular disease
3. Unipolar depressive disorders
4. Perinatal conditions
5. Osteoarthritis
6. Drug-use disorders
7. Cirrhosis of the liver
8. Hearing loss, adult onset
9. Diabetes mellitus
10. Vision disorders, age-related
892 192
163 411
122 449
61 490
37 345
24 362
21 844
21 203
19 467
17 864
17 793
100.0
18.3
13.7
6.9
4.2
2.7
2.4
2.4
2.2
2.0
2.0
GERMANY
Total
deaths
All causes
815 401
1. Ischaemic heart disease
172 717
2. Cerebrovascular disease
79 326
3. Trachea, bronchus and lung cancer
42 079
4. Colon and rectum cancer
32 424
5. Chronic obstructive pulmonary disease
21 948
6. Diabetes mellitus
20 873
7. Lower respiratory infections
20 608
8. Breast cancer
19 660
9. Hypertensive heart disease
18 302
10. Cirrhosis of the liver
17 979
100.0
21.2
9.7
5.2
4.0
2.7
2.6
2.5
2.4
2.2
2.2
All causes
10 414 377
1. Ischaemic heart disease
871 228
2. Unipolar depressive disorders
818 642
3. Alcohol-use disorders
521 875
4. Cerebrovascular disease
513 718
5. Hearing loss, adult onset
393 423
6. Alzheimer’s and other dementias
377 824
7. Trachea, bronchus and lung cancer
353 787
8. Chronic obstructive pulmonary disease 334 100
9. Cirrhosis of the liver
264 492
10. Osteoarthritis
251 575
100.0
8.4
7.9
5.0
4.9
3.8
3.6
3.4
3.2
2.5
2.4
GREECE
Causes
DALYs
All causes
113 981
1. Cerebrovascular disease
22 694
2. Ischaemic heart disease
16 825
3. Trachea, bronchus and lung cancer
6 274
4. Colon and rectum cancer
2 948
5. Upper respiratory infections
2 375
6. Road-traffic accidents
2 152
7. Liver cancer
2 038
8. Breast cancer
1 999
9. Stomach cancer
1 831
10. Chronic obstructive pulmonary disease
1 784
100.0
19.9
14.8
5.5
2.6
2.1
1.9
1.8
1.8
1.6
1.6
All causes
1. Cerebrovascular disease
2. Ischaemic heart disease
3. Unipolar depressive disorders
4. Road-traffic accidents
5. Hearing loss, adult onset
6. Alzheimer’s and other dementias
7. Trachea, bronchus and lung cancer
8. Alcohol-use disorders
9. Diabetes mellitus
10. Osteoarthritis
1 393 137
130 517
111 885
72 775
51 404
50 397
50 146
48 553
48 424
38 437
32 509
100.0
9.4
8.0
5.2
3.7
3.6
3.6
3.5
3.5
2.8
2.3
HUNGARY
Member
State
99
All causes
122 161
1. Ischaemic heart disease
29 420
2. Cerebrovascular disease
16 757
3. Trachea, bronchus and lung cancer
7 569
4. Cirrhosis of the liver
5 652
5. Colon and rectum cancer
4 596
6. Hypertensive heart disease
3 816
7. Falls
2 853
8. Self-inflicted injuries
2 795
9. Chronic obstructive pulmonary disease
2 786
10. Breast cancer
2 202
100.0
24.1
13.7
6.2
4.6
3.8
3.1
2.3
2.3
2.3
1.8
All causes
1 778 886
1. Ischaemic heart disease
186 226
2. Cerebrovascular disease
121 473
3. Unipolar depressive disorders
104 867
4. Cirrhosis of the liver
93 358
5. Alcohol-use disorders
82 576
6. Trachea, bronchus and lung cancer
76 036
7. Hearing loss, adult onset
54 648
8. Chronic obstructive pulmonary disease
48 778
9. Self-inflicted injuries
48 137
10. Osteoarthritis
46 469
100.0
10.5
6.8
5.9
5.2
4.6
4.3
3.1
2.7
2.7
2.6
100
T H E E U R O P E A N H E A LT H R E P O R T 2 0 0 5
Table 4 contd
Mortality
Causes
Total
DALYs
% of
total
ICELAND
% of
total
All causes
1. Ischaemic heart disease
2. Cerebrovascular disease
3. Trachea, bronchus and lung cancer
4. Alzheimer’s and other dementias
5. Lower respiratory infections
6. Chronic obstructive pulmonary disease
7. Colon and rectum cancer
8. Breast cancer
9. Prostate cancer
10. Pancreatic cancer
1 905
416
189
115
101
89
71
59
48
46
39
100.0
21.8
9.9
6.0
5.3
4.7
3.7
3.1
2.5
2.4
2.0
All causes
1. Unipolar depressive disorders
2. Ischaemic heart disease
3. Cerebrovascular disease
4. Alzheimer’s and other dementias
5. Hearing loss, adult onset
6. Chronic obstructive pulmonary disease
7. Trachea, bronchus and lung cancer
8. Self-inflicted injuries
9. Alcohol-use disorders
10. Road-traffic accidents
28 340
2 900
1 940
1 192
1 117
1 069
1 054
954
830
778
688
100.0
10.2
6.8
4.2
3.9
3.8
3.7
3.4
2.9
2.7
2.4
IRELAND
Total
deaths
All causes
1. Ischaemic heart disease
2. Lower respiratory infections
3. Cerebrovascular disease
4. Trachea, bronchus and lung cancer
5. Chronic obstructive pulmonary disease
6. Colon and rectum cancer
7. Breast cancer
8. Prostate cancer
9. Lymphomas, multiple myeloma
10. Self-inflicted injuries
31 236
6 527
2 667
2 650
1 596
1 558
1 014
742
601
491
458
100.0
20.9
8.5
8.5
5.1
5.0
3.2
2.4
1.9
1.6
1.5
All causes
487 635
1. Unipolar depressive disorders
40 534
2. Ischaemic heart disease
37 464
3. Alcohol-use disorders
26 143
4. Cerebrovascular disease
19 947
5. Chronic obstructive pulmonary disease
18 711
6. Hearing loss, adult onset
14 363
7. Alzheimer’s and other dementias
12 862
8. Road-traffic accidents
12 510
9. Asthma
12 199
10. Trachea, bronchus and lung cancer
11 995
100.0
8.3
7.7
5.4
4.1
3.8
2.9
2.6
2.6
2.5
2.5
ISRAEL
Causes
DALYs
All causes
1. Ischaemic heart disease
2. Diabetes mellitus
3. Cerebrovascular disease
4. Colon and rectum cancer
5. Trachea, bronchus and lung cancer
6. Breast cancer
7. Chronic obstructive pulmonary disease
8. Nephritis and nephrosis
9. Lower respiratory infections
10. Lymphomas, multiple myeloma
35 355
5 705
2 813
2 233
1 537
1 239
1 172
968
956
835
804
100.0
16.1
8.0
6.3
4.3
3.5
3.3
2.7
2.7
2.4
2.3
All causes
1. Unipolar depressive disorders
2. Ischaemic heart disease
3. Diabetes mellitus
4. Hearing loss, adult onset
5. Alzheimer’s and other dementias
6. Perinatal conditions
7. Cerebrovascular disease
8. Congenital anomalies
9. Endocrine disorders
10. Drug-use disorders
658 655
82 393
29 866
22 344
20 415
18 480
17 569
17 345
16 640
15 978
15 071
100.0
12.5
4.5
3.4
3.1
2.8
2.7
2.6
2.5
2.4
2.3
ITALY
Member
State
All causes
570 710
1. Ischaemic heart disease
92 928
2. Cerebrovascular disease
69 075
3. Trachea, bronchus and lung cancer
32 114
4. Hypertensive heart disease
20 566
5. Chronic obstructive pulmonary disease
20 042
6. Diabetes mellitus
19 335
7. Colon and rectum cancer
17 875
8. Lower respiratory infections
14 604
9. Alzheimer’s and other dementias
13 627
10. Breast cancer
11 625
100.0
16.3
12.1
5.6
3.6
3.5
3.4
3.1
2.6
2.4
2.0
All causes
1. Unipolar depressive disorders
2. Ischaemic heart disease
3. Cerebrovascular disease
4. Alzheimer’s and other dementias
5. Hearing loss, adult onset
6. Diabetes mellitus
7. Trachea bronchus lung cancers
8. Alcohol-use disorders
9. Road-traffic accidents
10. Osteoarthritis
6 789 291
464 873
450 953
385 564
304 193
272 459
253 447
238 299
227 530
182 555
177 068
100.0
6.8
6.6
5.7
4.5
4.0
3.7
3.5
3.4
2.7
2.6
A N N E X TA B L E 4
Mortality
Causes
Total
DALYs
% of
total
KAZAKHSTAN
% of
total
All causes
184 078
1. Ischaemic heart disease
51 948
2. Cerebrovascular disease
26 874
3. Poisonings
9 023
4. Self-inflicted injuries
5 746
5. Hypertensive heart disease
5 639
6. Chronic obstructive pulmonary disease
5 218
7. Tuberculosis
4 828
8. Trachea bronchus lung cancers
4 420
9. Lower respiratory infections
4 379
10. Cirrhosis of the liver
4 358
100.0
28.2
14.6
4.9
3.1
3.1
2.8
2.6
2.4
2.4
2.4
All causes
3 752 121
1. Ischaemic heart disease
409 227
2. Cerebrovascular disease
248 561
3. Poisonings
186 699
4. Unipolar depressive disorders
163 543
5. Self-inflicted injuries
137 970
6. Perinatal conditions
119 481
7. Tuberculosis
118 961
8. Lower respiratory infections
109 198
9. Violence
104 789
10. Chronic obstructive pulmonary disease
97 422
100.0
10.9
6.6
5.0
4.4
3.7
3.2
3.2
2.9
2.8
2.6
KYRGYZSTAN
Total
deaths
All causes
1. Ischaemic heart disease
2. Cerebrovascular disease
3. Chronic obstructive pulmonary disease
4. Perinatal conditions
5. Lower respiratory infections
6. Cirrhosis of the liver
7. Tuberculosis
8. Stomach cancer
9. Nephritis and nephrosis
10. Self-inflicted injuries
45 256
10 850
8 366
2 873
2 158
2 116
1 788
1 047
781
768
750
100.0
24.0
18.5
6.3
4.8
4.7
3.9
2.3
1.7
1.7
1.7
All causes
1 141 177
1. Perinatal conditions
92 799
2. Cerebrovascular disease
84 183
3. Ischaemic heart disease
84 092
4. Lower respiratory infections
63 417
5. Unipolar depressive disorders
57 911
6. Chronic obstructive pulmonary disease
47 784
7. Congenital anomalies
31 682
8. Cirrhosis of the liver
31 659
9. Tuberculosis
26 126
10. Diarrhoeal diseases
25 942
100.0
8.1
7.4
7.4
5.6
5.1
4.2
2.8
2.8
2.3
2.3
LATVIA
Causes
DALYs
All causes
1. Ischaemic heart disease
2. Cerebrovascular disease
3. Trachea, bronchus and lung cancer
4. Self-inflicted injuries
5. Colon and rectum cancer
6. Inflammatory heart diseases
7. Stomach cancer
8. Road-traffic accidents
9. Falls
10. Breast cancer
33 451
9 928
7 278
1 145
709
678
665
652
583
450
437
100.0
29.7
21.8
3.4
2.1
2.0
2.0
1.9
1.7
1.3
1.3
All causes
1. Ischaemic heart disease
2. Cerebrovascular disease
3. Unipolar depressive disorders
4. Alcohol-use disorders
5. Road-traffic accidents
6. Inflammatory heart diseases
7. Self-inflicted injuries
8. Hearing loss, adult onset
9. Osteoarthritis
10. Trachea, bronchus and lung cancer
482 223
60 445
45 102
24 848
20 747
15 991
13 916
13 328
12 823
10 804
10 139
100.0
12.5
9.4
5.2
4.3
3.3
2.9
2.8
2.7
2.2
2.1
LITHUANIA
Member
State
101
All causes
1. Ischaemic heart disease
2. Cerebrovascular disease
3. Self-inflicted injuries
4. Trachea, bronchus and lung cancer
5. Chronic obstructive pulmonary disease
6. Colon and rectum cancer
7. Stomach cancer
8. Road-traffic accidents
9. Poisonings
10. Cirrhosis of the liver
41 060
14 662
5 089
1 577
1 467
963
953
828
709
670
666
100.0
35.7
12.4
3.8
3.6
2.3
2.3
2.0
1.7
1.6
1.6
All causes
1. Ischaemic heart disease
2. Unipolar depressive disorders
3. Cerebrovascular disease
4. Self-inflicted injuries
5. Road-traffic accidents
6. Alcohol-use disorders
7. Hearing loss, adult onset
8. Osteoarthritis
9. Violence
10. Trachea, bronchus and lung cancer
625 222
77 874
36 789
34 155
30 657
19 637
18 200
18 067
15 323
14 094
12 675
100.0
12.5
5.9
5.5
4.9
3.1
2.9
2.9
2.5
2.3
2.0
102
T H E E U R O P E A N H E A LT H R E P O R T 2 0 0 5
Table 4 contd
Mortality
Causes
Total
DALYs
% of
total
LUXEMBOURG
% of
total
All causes
1. Ischaemic heart disease
2. Cerebrovascular disease
3. Trachea, bronchus and lung cancer
4. Colon and rectum cancer
5. Chronic obstructive pulmonary disease
6. Lower respiratory infections
7. Breast cancer
8. Alzheimer’s and other dementias
9. Cirrhosis of the liver
10. Self-inflicted injuries
3 410
455
390
183
128
109
104
91
89
75
72
100.0
13.3
11.4
5.4
3.7
3.2
3.0
2.7
2.6
2.2
2.1
All causes
1. Unipolar depressive disorders
2. Alcohol-use disorders
3. Cerebrovascular disease
4. Ischaemic heart disease
5. Hearing loss, adult onset
6. Road-traffic accidents
7. Alzheimer’s and other dementias
8. Chronic obstructive pulmonary disease
9. Trachea, bronchus and lung cancer
10. Self-inflicted injuries
55 069
5 255
3 324
2 971
2 778
1 915
1 800
1 779
1 765
1 563
1 296
100.0
9.5
6.0
5.4
5.0
3.5
3.3
3.2
3.2
2.8
2.4
MALTA
Total
deaths
All causes
1. Ischaemic heart disease
2. Cerebrovascular disease
3. Lower respiratory infections
4. Trachea, bronchus and lung cancer
5. Colon and rectum cancer
6. Diabetes mellitus
7. Breast cancer
8. Chronic obstructive pulmonary disease
9. Skin conditions
10. Nephritis and nephrosis
2 962
773
316
230
133
98
92
89
73
54
50
100.0
26.1
10.7
7.8
4.5
3.3
3.1
3.0
2.5
1.8
1.7
All causes
1. Ischaemic heart disease
2. Unipolar depressive disorders
3. Cerebrovascular disease
4. Diabetes mellitus
5. Hearing loss, adult onset
6. Alzheimer’s and other dementias
7. Chronic obstructive pulmonary disease
8. Trachea, bronchus and lung cancer
9. Alcohol-use disorders
10. Osteoarthritis
43 508
4 502
3 182
2 368
1 875
1 607
1 362
1 338
1 106
1 050
1 024
100.0
10.3
7.3
5.4
4.3
3.7
3.1
3.1
2.5
2.4
2.4
MONACO
Causes
DALYs
All causes
1. Ischaemic heart disease
2. Cerebrovascular disease
3. Trachea, bronchus and lung cancer
4. Lower respiratory infections
5. Colon and rectum cancer
6. Chronic obstructive pulmonary disease
7. Endocrine disorders
8. Breast cancer
9. Falls
10. Diabetes mellitus
261
27
22
14
11
9
8
6
6
5
5
100.0
10.4
8.4
5.2
4.3
3.3
3.1
2.4
2.3
2.0
1.9
All causes
1. Unipolar depressive disorders
2. Alcohol-use disorders
3. Hearing loss, adult onset
4. Cerebrovascular disease
5. Ischaemic heart disease
6. Alzheimer’s and other dementias
7. Chronic obstructive pulmonary disease
8. Trachea, bronchus and lung cancer
9. Road-traffic accidents
10. Endocrine disorders
3 876
337
213
145
142
139
138
117
115
107
104
100.0
8.7
5.5
3.7
3.7
3.6
3.6
3.0
3.0
2.8
2.7
NETHERLANDS
Member
State
All causes
139 374
1. Ischaemic heart disease
19 045
2. Cerebrovascular disease
12 459
3. Trachea, bronchus and lung cancer
9 054
4. Lower respiratory infections
8 016
5. Chronic obstructive pulmonary disease
7 226
6. Alzheimer’s and other dementias
5 847
7. Colon and rectum cancer
5 133
8. Breast cancer
3 956
9. Diabetes mellitus
3 582
10. Prostate cancer
2 914
100.0
13.7
8.9
6.5
5.8
5.2
4.2
3.7
2.8
2.6
2.1
All causes
1 868 545
1. Unipolar depressive disorders
145 864
2. Ischaemic heart disease
116 880
3. Chronic obstructive pulmonary disease
97 583
4. Cerebrovascular disease
86 157
5. Trachea, bronchus and lung cancer
72 975
6. Alzheimer’s and other dementias
70 892
7. Hearing loss, adult onset
69 337
8. Alcohol-use disorders
68 738
9. Osteoarthritis
43 099
10. Breast cancer
42 988
100.0
7.8
6.3
5.2
4.6
3.9
3.8
3.7
3.7
2.3
2.3
A N N E X TA B L E 4
Mortality
Causes
Total
DALYs
% of
total
NORWAY
% of
total
All causes
1. Ischaemic heart disease
2. Cerebrovascular disease
3. Lower respiratory infections
4. Trachea, bronchus and lung cancer
5. Colon and rectum cancer
6. Chronic obstructive pulmonary disease
7. Prostate cancer
8. Alzheimer’s and other dementias
9. Falls
10. Breast cancer
45 207
8 886
4 817
2 749
1 885
1 868
1 684
1 281
1 087
943
892
100.0
19.7
10.7
6.1
4.2
4.1
3.7
2.8
2.4
2.1
2.0
All causes
520 406
1. Unipolar depressive disorders
46 167
2. Ischaemic heart disease
39 668
3. Cerebrovascular disease
25 324
4. Chronic obstructive pulmonary disease
23 033
5. Alzheimer’s and other dementias
21 191
6. Hearing loss, adult onset
18 755
7. Alcohol-use disorders
15 226
8. Trachea, bronchus and lung cancer
14 948
9. Drug-use disorders
13 063
10. Colon and rectum cancer
12 637
100.0
8.9
7.6
4.9
4.4
4.1
3.6
2.9
2.9
2.5
2.4
POLAND
Total
deaths
All causes
351 944
1. Ischaemic heart disease
77 151
2. Cerebrovascular disease
43 032
3. Trachea, bronchus and lung cancer
22 831
4. Colon and rectum cancer
11 186
5. Stomach cancer
7 039
6. Lower respiratory infections
6 818
7. Self-inflicted injuries
6 692
8. Road-traffic accidents
6 012
9. Breast cancer
5 948
10. Chronic obstructive pulmonary disease
5 941
100.0
21.9
12.2
6.5
3.2
2.0
1.9
1.9
1.7
1.7
1.7
All causes
1. Ischaemic heart disease
2. Unipolar depressive disorders
3. Cerebrovascular disease
4. Trachea, bronchus and lung cancer
5. Osteoarthritis
6. Alcohol-use disorders
7. Road-traffic accidents
8. Hearing loss, adult onset
9. Self-inflicted injuries
10. Vision disorders, age-related
5 832 411
533 090
467 645
337 626
214 605
182 809
178 498
152 199
142 890
137 566
127 710
100.0
9.1
8.0
5.8
3.7
3.1
3.1
2.6
2.4
2.4
2.2
PORTUGAL
Causes
DALYs
All causes
1. Cerebrovascular disease
2. Ischaemic heart disease
3. Lower respiratory infections
4. Diabetes mellitus
5. Colon and rectum cancer
6. Trachea, bronchus and lung cancer
7. Stomach cancer
8. Chronic obstructive pulmonary disease
9. Prostate cancer
10. Cirrhosis of the liver
94 312
20 069
10 927
5 384
3 402
3 241
3 154
2 952
2 569
1 911
1 896
100.0
21.3
11.6
5.7
3.6
3.4
3.3
3.1
2.7
2.0
2.0
All causes
1 415 476
1. Cerebrovascular disease
145 965
2. Unipolar depressive disorders
76 723
3. Ischaemic heart disease
69 821
4. Alcohol-use disorders
60 323
5. Hearing loss, adult onset
43 514
6. Road-traffic accidents
43 328
7. Alzheimer’s and other dementias
43 191
8. Chronic obstructive pulmonary disease
42 410
9. Diabetes mellitus
41 896
10. HIV/AIDS
36 983
100.0
10.3
5.4
4.9
4.3
3.1
3.1
3.1
3.0
3.0
2.6
REPUBLIC OF MOLDOVA
Member
State
103
All causes
1. Ischaemic heart disease
2. Cerebrovascular disease
3. Cirrhosis of the liver
4. Chronic obstructive pulmonary disease
5. Trachea, bronchus and lung cancer
6. Lower respiratory infections
7. Self-inflicted injuries
8. Tuberculosis
9. Colon and rectum cancer
10. Road-traffic accidents
48 206
18 559
7 848
3 809
1 671
950
845
782
694
686
670
100.0
38.5
16.3
7.9
3.5
2.0
1.8
1.6
1.4
1.4
1.4
All causes
883 014
1. Ischaemic heart disease
110 615
2. Cerebrovascular disease
72 774
3. Alcohol-use disorders
61 483
4. Cirrhosis of the liver
53 605
5. Unipolar depressive disorders
46 127
6. Chronic obstructive pulmonary disease
22 884
7. Congenital anomalies
20 936
8. Road-traffic accidents
20 004
9. Hearing loss, adult onset
19 937
10. Lower respiratory infections
17 593
100.0
12.5
8.2
7.0
6.1
5.2
2.6
2.4
2.3
2.3
2.0
104
T H E E U R O P E A N H E A LT H R E P O R T 2 0 0 5
Table 4 contd
Mortality
Causes
ROMANIA
% of
total
All causes
258 675
1. Ischaemic heart disease
60 718
2. Cerebrovascular disease
52 272
3. Hypertensive heart disease
16 858
4. Cirrhosis of the liver
10 996
5. Trachea, bronchus and lung cancer
8 904
6. Lower respiratory infections
6 367
7. Chronic obstructive pulmonary disease
5 743
8. Colon and rectum cancer
4 612
9. Stomach cancer
4 394
10. Breast cancer
3 392
100.0
23.5
20.2
6.5
4.3
3.4
2.5
2.2
1.8
1.7
1.3
All causes
1. Cerebrovascular disease
2. Ischaemic heart disease
3. Unipolar depressive disorders
4. Cirrhosis of the liver
5. Alcohol-use disorders
6. Osteoarthritis
7. Lower respiratory infections
8. Hypertensive heart disease
9. Trachea, bronchus and lung cancer
10. Hearing loss, adult onset
RUSSIAN FEDERATION
Total
deaths
All causes
1. Ischaemic heart disease
2. Cerebrovascular disease
3. Poisonings
4. Self-inflicted injuries
5. Trachea, bronchus and lung cancer
6. Violence
7. Road-traffic accidents
8. Stomach cancer
9. Colon and rectum cancer
10. Cirrhosis of the liver
2 405 721
711 571
533 675
66 930
59 015
58 899
47 461
44 580
44 557
38 141
37 426
100.0
29.6
22.2
2.8
2.5
2.4
2.0
1.9
1.9
1.6
1.6
All causes
1. Ischaemic heart disease
2. Cerebrovascular disease
3. Unipolar depressive disorders
4. Violence
5. Self-inflicted injuries
6. Road-traffic accidents
7. Poisonings
8. Alcohol-use disorders
9. Hearing loss, adult onset
10. Tuberculosis
SAN MARINO
Causes
DALYs
All causes
1. Ischaemic heart disease
2. Cerebrovascular disease
3. Trachea, bronchus and lung cancer
4. Stomach cancer
5. Lower respiratory infections
6. Lymphomas, multiple myeloma
7. Colon and rectum cancer
8. Prostate cancer
9. Inflammatory heart diseases
10. Breast cancer
260
40
26
18
12
9
8
6
5
5
4
100.0
15.4
9.9
6.8
4.4
3.3
3.2
2.4
1.9
1.9
1.6
All causes
1. Unipolar depressive disorders
2. Ischaemic heart disease
3. Cerebrovascular disease
4. Hearing loss, adult onset
5. Alzheimer’s and other dementias
6. Trachea, bronchus and lung cancer
7. Alcohol-use disorders
8. Osteoarthritis
9. Road-traffic accidents
10. Diabetes mellitus
SERBIA AND MONTENEGRO
Member
State
All causes
120 948
1. Ischaemic heart disease
23 610
2. Cerebrovascular disease
21 756
3. Trachea, bronchus and lung cancer
4 986
4. Inflammatory heart diseases
4 903
5. Diabetes mellitus
3 239
6. Chronic obstructive pulmonary disease
2 730
7. Colon and rectum cancer
2 576
8. Breast cancer
1 870
9. Cirrhosis of the liver
1 818
10. Other genitourinary-system diseases
1 810
100.0
19.5
18.0
4.1
4.1
2.7
2.3
2.1
1.5
1.5
1.5
All causes
1. Cerebrovascular disease
2. Ischaemic heart disease
3. Unipolar depressive disorders
4. Alcohol-use disorders
5. Other genitourinary-system diseases
6. Trachea, bronchus and lung cancer
7. Osteoarthritis
8. Perinatal conditions
9. Hearing loss, adult onset
10. Diabetes mellitus
Total
DALYs
% of
total
4 106 104
416 656
403 640
268 936
159 426
125 986
107 647
104 787
103 018
91 790
86 627
100.0
10.1
9.8
6.5
3.9
3.1
2.6
2.6
2.5
2.2
2.1
39 409 946
5 472 308
3 930 367
1 574 695
1 459 927
1 297 152
1 292 752
1 272 366
1 258 936
765 988
700 997
100.0
13.9
10.0
4.0
3.7
3.3
3.3
3.2
3.2
1.9
1.8
3 042
245
219
158
130
129
116
107
84
81
78
100.0
8.1
7.2
5.2
4.3
4.2
3.8
3.5
2.8
2.7
2.6
1 823 369
182 445
173 717
123 248
64 796
63 507
50 952
49 912
41 560
40 272
38 588
100.0
10.0
9.5
6.8
3.6
3.5
2.8
2.7
2.3
2.2
2.1
A N N E X TA B L E 4
Mortality
Causes
Total
DALYs
% of
total
SLOVAKIA
% of
total
All causes
1. Ischaemic heart disease
2. Cerebrovascular disease
3. Hypertensive heart disease
4. Trachea, bronchus and lung cancer
5. Colon and rectum cancer
6. Lower respiratory infections
7. Cirrhosis of the liver
8. Breast cancer
9. Stomach cancer
10. Diabetes mellitus
49 852
14 609
4 445
3 281
2 112
1 801
1 409
1 313
852
810
783
100.0
29.3
8.9
6.6
4.2
3.6
2.8
2.6
1.7
1.6
1.6
All causes
1. Ischaemic heart disease
2. Unipolar depressive disorders
3. Alcohol-use disorders
4. Cerebrovascular disease
5. Osteoarthritis
6. Hypertensive heart disease
7. Cirrhosis of the liver
8. Hearing loss, adult onset
9. Trachea, bronchus and lung cancer
10. Vision disorders, age-related
834 289
83 412
65 871
33 199
31 508
25 284
22 720
22 621
19 526
19 263
16 923
100.0
10.0
7.9
4.0
3.8
3.0
2.7
2.7
2.3
2.3
2.0
SLOVENIA
Total
deaths
All causes
1. Ischaemic heart disease
2. Cerebrovascular disease
3. Trachea, bronchus and lung cancer
4. Inflammatory heart diseases
5. Cirrhosis of the liver
6. Colon and rectum cancer
7. Chronic obstructive pulmonary disease
8. Self-inflicted injuries
9. Lower respiratory infections
10. Diabetes mellitus
18 192
2 803
2 003
982
793
786
651
608
586
575
564
100.0
15.4
11.0
5.4
4.4
4.3
3.6
3.3
3.2
3.2
3.1
All causes
282 355
1. Unipolar depressive disorders
26 947
2. Ischaemic heart disease
17 813
3. Cerebrovascular disease
17 284
4. Alcohol-use disorders
12 595
5. Cirrhosis of the liver
12 094
6. Self-inflicted injuries
10 458
7. Trachea, bronchus and lung cancer
9 154
8. Hearing loss, adult onset
8 854
9. Road-traffic accidents
8 247
10. Chronic obstructive pulmonary disease
7 919
100.0
9.5
6.3
6.1
4.5
4.3
3.7
3.2
3.1
2.9
2.8
SPAIN
Causes
DALYs
All causes
355 695
1. Ischaemic heart disease
45 018
2. Cerebrovascular disease
34 880
3. Trachea, bronchus and lung cancer
18 298
4. Alzheimer’s and other dementias
17 341
5. Chronic obstructive pulmonary disease
17 148
6. Colon and rectum cancer
13 127
7. Diabetes mellitus
9 965
8. Lower respiratory infections
9 805
9. Stomach cancer
6 569
10. Road-traffic accidents
6 489
100.0
12.7
9.8
5.1
4.9
4.8
3.7
2.8
2.8
1.8
1.8
All causes
4 951 588
1. Unipolar depressive disorders
274 925
2. Ischaemic heart disease
254 464
3. Alcohol-use disorders
227 749
4. Cerebrovascular disease
220 220
5. Alzheimer’s and other dementias
216 950
6. Hearing loss, adult onset
179 798
7. Chronic obstructive pulmonary disease 165 829
8. Road-traffic accidents
165 584
9. Trachea, bronchus and lung cancer
154 604
10. Drug-use disorders
145 699
100.0
5.6
5.1
4.6
4.4
4.4
3.6
3.3
3.3
3.1
2.9
SWEDEN
Member
State
105
All causes
1. Ischaemic heart disease
2. Cerebrovascular disease
3. Alzheimer’s and other dementias
4. Lower respiratory infections
5. Trachea, bronchus and lung cancer
6. Prostate cancer
7. Colon and rectum cancer
8. Chronic obstructive pulmonary disease
9. Diabetes mellitus
10. Breast cancer
100.0
22.1
11.0
5.5
3.4
3.2
3.0
3.0
2.6
2.2
1.8
All causes
977 415
1. Unipolar depressive disorders
95 031
2. Ischaemic heart disease
86 116
3. Cerebrovascular disease
52 520
4. Alzheimer’s and other dementias
52 277
5. Hearing loss, adult onset
39 099
6. Alcohol-use disorders
35 028
7. Chronic obstructive pulmonary disease
28 598
8. Osteoarthritis
25 508
9. Trachea, bronchus and lung cancer
22 603
10. Self-inflicted injuries
20 218
100.0
9.7
8.8
5.4
5.3
4.0
3.6
2.9
2.6
2.3
2.1
91 085
20 122
9 984
5 024
3 114
2 954
2 742
2 702
2 341
1 994
1 637
106
T H E E U R O P E A N H E A LT H R E P O R T 2 0 0 5
Table 4 contd
Mortality
% of
total
Causes
Total
DALYs
% of
total
All causes
1. Ischaemic heart disease
2. Cerebrovascular disease
3. Trachea, bronchus and lung cancer
4. Alzheimer’s and other dementias
5. Lower respiratory infections
6. Chronic obstructive pulmonary disease
7. Diabetes mellitus
8. Colon and rectum cancer
9. Prostate cancer
10. Hypertensive heart disease
60 919
10 746
4 508
2 893
2 867
2 518
1 980
1 855
1 801
1 514
1 374
100.0
17.6
7.4
4.7
4.7
4.1
3.2
3.0
3.0
2.5
2.3
All causes
798 617
1. Unipolar depressive disorders
82 410
2. Ischaemic heart disease
49 624
3. Alzheimer’s and other dementias
37 445
4. Alcohol-use disorders
36 543
5. Hearing loss, adult onset
33 189
6. Cerebrovascular disease
26 201
7. Trachea, bronchus and lung cancer
24 504
8. Chronic obstructive pulmonary disease
22 679
9. Self-inflicted injuries
22 172
10. Osteoarthritis
21 426
100.0
10.3
6.2
4.7
4.6
4.2
3.3
3.1
2.8
2.8
2.7
All causes
1. Ischaemic heart disease
2. Hypertensive heart disease
3. Lower respiratory infections
4. Perinatal conditions
5. Cerebrovascular disease
6. Diarrhoeal diseases
7. Cirrhosis of the liver
8. Tuberculosis
9. Meningitis
10. Chronic obstructive pulmonary disease
54 286
11 447
6 276
5 474
3 088
3 048
2 032
1 303
1 155
1 096
1 028
100.0
21.1
11.6
10.1
5.7
5.6
3.7
2.4
2.1
2.0
1.9
All causes
1 374 273
1. Perinatal conditions
132 906
2. Lower respiratory infections
125 475
3. Ischaemic heart disease
83 634
4. Unipolar depressive disorders
68 596
5. Diarrhoeal diseases
68 332
6. Hypertensive heart disease
47 926
7. Meningitis
37 258
8. Tuberculosis
28 984
9. Chronic obstructive pulmonary disease
25 759
10. Cerebrovascular disease
25 174
100.0
9.7
9.1
6.1
5.0
5.0
3.5
2.7
2.1
1.9
1.8
All causes
1. Cerebrovascular disease
2. Inflammatory heart diseases
3. Ischaemic heart disease
4. War
5. Trachea, bronchus and lung cancer
6. Diabetes mellitus
7. Hypertensive heart disease
8. Stomach cancer
9. Colon and rectum cancer
10. Chronic obstructive pulmonary disease
18 972
3 772
3 219
2 544
803
674
615
475
392
369
309
100.0
19.9
17.0
13.4
4.2
3.6
3.2
2.5
2.1
1.9
1.6
All causes
1. Cerebrovascular disease
2. War
3. Unipolar depressive disorders
4. Ischaemic heart disease
5. Inflammatory heart diseases
6. Perinatal conditions
7. Osteoarthritis
8. Hearing loss, adult onset
9. Trachea, bronchus and lung cancer
10. Diabetes mellitus
326 031
30 091
26 142
24 263
22 280
17 853
10 232
9 167
7 171
7 150
6 610
100.0
9.2
8.0
7.4
6.8
5.5
3.1
2.8
2.2
2.2
2.0
All causes
436 920
102 552
1. Ischaemic heart disease
62 782
2. Cerebrovascular disease
19 513
3. Perinatal conditions
18 221
4. Chronic obstructive pulmonary disease
12 891
5. Lower respiratory infections
11 680
6. Hypertensive heart disease
10 121
7. Trachea, bronchus and lung cancer
7 642
8. Meningitis
6 942
9. Diarrhoeal diseases
6 679
10. Congenital anomalies
100.0
23.5
14.4
4.5
4.2
3.0
2.7
2.3
1.7
1.6
1.5
11 449 790
All causes
842 438
1. Ischaemic heart disease
818 907
2. Unipolar depressive disorders
767 718
3. Perinatal conditions
730 232
4. Cerebrovascular disease
383 673
5. Lower respiratory infections
6. Chronic obstructive pulmonary disease 317 991
310 417
7. Congenital anomalies
252 122
8. Osteoarthritis
249 240
9. Meningitis
235 894
10. Diarrhoeal diseases
100.0
7.4
7.2
6.7
6.4
3.4
2.8
2.7
2.2
2.2
2.1
TURKEY
SWITZERLAND
Total
deaths
TAJIKISTAN
Causes
DALYs
THE FORMER YUGOSLAV
REPUBLIC OF MACEDONIA
Member
State
A N N E X TA B L E 4
Mortality
Causes
Total
DALYs
% of
total
TURKMENISTAN
% of
total
All causes
1. Ischaemic heart disease
2. Hypertensive heart disease
3. Lower respiratory infections
4. Cerebrovascular disease
5. Tuberculosis
6. Cirrhosis of the liver
7. Diarrhoeal diseases
8. Perinatal conditions
9. Self-inflicted injuries
10. Diabetes mellitus
41 735
11 671
5 068
3 720
2 182
1 491
1 421
1 097
910
599
552
100.0
28.0
12.1
8.9
5.2
3.6
3.4
2.6
2.2
1.4
1.3
All causes
1. Lower respiratory infections
2. Ischaemic heart disease
3. Unipolar depressive disorders
4. Hypertensive heart disease
5. Perinatal conditions
6. Diarrhoeal diseases
7. Tuberculosis
8. Cirrhosis of the liver
9. Cerebrovascular disease
10. Congenital anomalies
1 070 033
114 409
102 191
55 051
51 101
40 553
38 911
36 958
28 496
22 071
17 493
100.0
10.7
9.6
5.1
4.8
3.8
3.6
3.5
2.7
2.1
1.6
UKRAINE
Total
deaths
All causes
782 993
1. Ischaemic heart disease
335 610
2. Cerebrovascular disease
126 117
3. Chronic obstructive pulmonary disease
25 304
4. Trachea, bronchus and lung cancer
18 953
5. Self-inflicted injuries
17 520
6. Poisonings
16 577
7. Stomach cancer
12 629
8. Cirrhosis of the liver
12 459
9. Colon and rectum cancer
12 413
10. HIV/AIDS
12 223
100.0
42.9
16.1
3.2
2.4
2.2
2.1
1.6
1.6
1.6
1.6
All causes
11 340 794
1. Ischaemic heart disease
2 067 811
2. Cerebrovascular disease
958 442
3. Unipolar depressive disorders
525 321
4. HIV/AIDS
354 531
5. Self-inflicted injuries
339 304
6. Chronic obstructive pulmonary disease 321 391
7. Poisonings
312 298
8. Hearing loss, adult onset
266 302
9. Violence
241 668
10. Cirrhosis of the liver
224 442
100.0
18.2
8.5
4.6
3.1
3.0
2.8
2.8
2.3
2.1
2.0
UNITED KINGDOM
Causes
DALYs
All causes
599 344
1. Ischaemic heart disease
120 530
2. Lower respiratory infections
65 395
3. Cerebrovascular disease
59 322
4. Trachea, bronchus and lung cancer
33 314
5. Chronic obstructive pulmonary disease
28 421
6. Colon and rectum cancer
19 350
7. Breast cancer
14 989
8. Alzheimer’s and other dementias
13 162
9. Prostate cancer
10 995
10. Lymphomas, multiple myeloma
8 431
100.0
20.1
10.9
9.9
5.6
4.7
3.2
2.5
2.2
1.8
1.4
All causes
7 555 040
1. Ischaemic heart disease
653 004
2. Unipolar depressive disorders
586 613
3. Chronic obstructive pulmonary disease 366 584
4. Cerebrovascular disease
365 846
5. Alcohol-use disorders
277 584
6. Alzheimer’s and other dementias
276 347
7. Hearing loss, adult onset
252 668
8. Trachea, bronchus and lung cancer
229 789
9. Lower respiratory infections
226 081
10. Drug-use disorders
162 131
100.0
8.6
7.8
4.9
4.8
3.7
3.7
3.3
3.0
3.0
2.1
UZBEKISTAN
Member
State
107
All causes
171 512
55 693
1. Ischaemic heart disease
23 436
2. Cerebrovascular disease
10 922
3. Lower respiratory infections
9 004
4. Hypertensive heart disease
6 695
5. Cirrhosis of the liver
4 854
6. Perinatal conditions
4 479
7. Inflammatory heart diseases
4 384
8. Tuberculosis
3 400
9. Chronic obstructive pulmonary disease
2 955
10. Diabetes mellitus
100.0
32.5
13.7
6.4
5.2
3.9
2.8
2.6
2.6
2.0
1.7
All causes
1. Ischaemic heart disease
2. Lower respiratory infections
3. Unipolar depressive disorders
4. Perinatal conditions
5. Cerebrovascular disease
6. Cirrhosis of the liver
7. Tuberculosis
8. Congenital anomalies
9. Hearing loss, adult onset
10. Anaemia
4 300 427
379 347
339 614
294 066
207 600
183 670
132 821
107 645
92 923
92 032
86 482
100.0
8.8
7.9
6.8
4.8
4.3
3.1
2.5
2.2
2.1
2.0
108
T H E E U R O P E A N H E A LT H R E P O R T 2 0 0 5
Table 5. Shares of total deaths and DALYs attributable to 10 leading risk factors in the WHO European Region, 2002
Risk factor
ALBANIA
1. High blood pressure
2. Tobacco
3. High cholesterol
4. High BMI
5. Low fruit and vegetable intake
6. Alcohol
7. Physical inactivity
8. Urban outdoor air pollution
9. Indoor smoke from solid-fuel use
10. Lead
22.0
21.6
11.0
10.0
6.3
5.7
5.3
1.7
1.3
1.1
1. Tobacco
2. High blood pressure
3. Alcohol
4. High BMI
5. High cholesterol
6. Low fruit and vegetable intake
7. Physical inactivity
8. Indoor smoke from solid-fuel use
9. Childhood and maternal underweight
10. Lead
ANDORRA
1. Tobacco
2. High blood pressure
3. High BMI
4. Physical inactivity
5. Low fruit and vegetable intake
6. Alcohol
7. Unsafe sex
8. Occupational airborne particulate matter
9. Illicit drugs
10. Urban outdoor air pollution
16.6
14.5
7.5
4.0
2.8
1.2
0.9
0.7
0.6
0.5
1. Tobacco
2. Alcohol
3. High BMI
4. High blood pressure
5. Physical inactivity
6. Illicit drugs
7. Low fruit and vegetable intake
8. Unsafe sex
9. Iron deficiency
10. Occupational airborne particulate matter
11.2
8.6
5.8
5.5
2.2
2.2
1.5
1.4
0.6
0.5
ARMENIA
DALYs
% of
total
1. High blood pressure
2. Tobacco
3. High BMI
4. High cholesterol
5. Physical inactivity
6. Low fruit and vegetable intake
7. Alcohol
8. Urban outdoor air pollution
9. Indoor smoke from solid-fuel use
10. Lead
22.9
19.6
18.5
17.5
9.2
9.0
4.8
2.2
1.6
1.3
1. Tobacco
2. High BMI
3. High blood pressure
4. High cholesterol
5. Alcohol
6. Physical inactivity
7. Low fruit and vegetable intake
8. Unsafe sex
9. Iron deficiency
10. Indoor smoke from solid-fuel use
12.3
9.9
8.5
7.8
4.6
4.2
4.0
2.0
1.9
1.2
AUSTRIA
Deaths
1. High blood pressure
2. Tobacco
3. High cholesterol
4. High BMI
5. Physical inactivity
6. Low fruit and vegetable intake
7. Alcohol
8. Unsafe sex
9. Urban outdoor air pollution
10. Illicit drugs
22.8
15.8
14.3
9.6
6.0
4.2
2.2
0.8
0.5
0.4
1. Tobacco
2. Alcohol
3. High blood pressure
4. High BMI
5. High cholesterol
6. Physical inactivity
7. Low fruit and vegetable intake
8. Illicit drugs
9. Unsafe sex
10. Childhood sexual abuse
11.0
9.2
8.9
6.7
6.6
3.0
2.2
1.8
1.0
0.5
AZERBAIJAN
Member
State
Risk factor
1. High blood pressure
2. High cholesterol
3. High BMI
4. Tobacco
5. Low fruit and vegetable intake
6. Physical inactivity
7. Alcohol
8. Indoor smoke from solid-fuel use
9. Urban outdoor air pollution
10. Childhood and maternal underweight
21.6
17.8
15.8
9.9
9.0
8.5
5.1
2.5
2.0
1.7
1. High BMI
2. Tobacco
3. High cholesterol
4. High blood pressure
5. Alcohol
6. Low fruit and vegetable intake
7. Physical inactivity
8. Indoor smoke from solid-fuel use
9. Childhood and maternal underweight
10. Iron deficiency
Source: data from Mathers C et al. Global burden of disease in 2002: data sources, methods and results. Geneva, World Health Organization, 2004 (http://www3.
who.int/whosis/menu.cfm?path=evidence,burden,burden_gbd2000docs,burden_gbd2000docs_DP54&language=english, accessed 25 May 2005).
% of
total
9.2
7.5
6.5
5.2
4.4
2.5
2.2
1.5
1.3
1.3
7.8
6.9
6.8
6.7
3.8
3.5
3.4
3.3
2.7
2.5
A N N E X TA B L E 5
Risk factor
% of
total
BELARUS
1. High blood pressure
2. High cholesterol
3. Tobacco
4. Low fruit and vegetable intake
5. High BMI
6. Physical inactivity
7. Alcohol
8. Urban outdoor air pollution
9. Illicit drugs
10. Lead
35.3
29.2
15.4
15.4
13.4
10.9
10.1
1.4
1.3
1.1
1. High blood pressure
2. Alcohol
3. High cholesterol
4. Tobacco
5. High BMI
6. Low fruit and vegetable intake
7. Physical inactivity
8. Illicit drugs
9. Unsafe sex
10. Lead
16.7
14.3
14.1
11.6
9.6
7.9
5.5
2.2
1.4
1.1
BELGIUM
1. Tobacco
2. High blood pressure
3. High cholesterol
4. High BMI
5. Physical inactivity
6. Low fruit and vegetable intake
7. Occupational airborne particulate matter
8. Unsafe sex
9. Urban outdoor air pollution
10. Occupational carcinogens
23.3
13.4
11.2
7.3
4.5
3.3
0.7
0.7
0.5
0.5
1. Tobacco
2. Alcohol
3. High cholesterol
4. High blood pressure
5. High BMI
6. Physical inactivity
7. Low fruit and vegetable intake
8. Illicit drugs
9. Unsafe sex
10. Occupational airborne particulate matter
15.8
6.6
6.1
6.1
5.9
2.6
1.9
1.6
0.8
0.7
BOSNIA AND HERZEGOVINA
DALYs
% of
total
1. High blood pressure
2. Tobacco
3. High cholesterol
4. High BMI
5. Low fruit and vegetable intake
6. Physical inactivity
7. Alcohol
8. Urban outdoor air pollution
9. Lead
10. Illicit drugs
28.5
21.1
10.6
10.3
5.8
5.3
4.0
1.9
1.1
0.5
1. Tobacco
2. High blood pressure
3. High BMI
4. High cholesterol
5. Alcohol
6. Low fruit and vegetable intake
7. Physical inactivity
8. Lead
9. Illicit drugs
10. Urban outdoor air pollution
14.7
13.3
7.4
6.0
5.8
3.2
3.0
1.2
1.2
0.8
BULGARIA
Deaths
1. High blood pressure
2. High cholesterol
3. High BMI
4. Tobacco
5. Low fruit and vegetable intake
6. Physical inactivity
7. Alcohol
8. Urban outdoor air pollution
9. Lead
10. Unsafe sex
40.0
14.3
14.2
13.5
7.4
7.1
6.5
2.0
1.3
0.8
1. High blood pressure
2. Tobacco
3. High BMI
4. High cholesterol
5. Alcohol
6. Low fruit and vegetable intake
7. Physical inactivity
8. Illicit drugs
9. Lead
10. Unsafe sex
20.4
12.4
10.9
8.4
7.9
4.3
4.3
1.8
1.3
1.2
CROATIA
Member
State
Risk factor
109
1. High blood pressure
2. Tobacco
3. High cholesterol
4. High BMI
5. Physical inactivity
6. Low fruit and vegetable intake
7. Alcohol
8. Urban outdoor air pollution
9. Unsafe sex
10. Occupational carcinogens
26.4
21.3
18.3
11.9
6.9
5.2
4.1
0.6
0.6
0.4
1. Tobacco
2. High blood pressure
3. High cholesterol
4. Alcohol
5. High BMI
6. Physical inactivity
7. Low fruit and vegetable intake
8. Illicit drugs
9. Unsafe sex
10. Childhood sexual abuse
15.8
13.8
10.7
9.7
9.2
4.1
3.2
1.6
0.8
0.4
110
T H E E U R O P E A N H E A LT H R E P O R T 2 0 0 5
Table 5 contd
Risk factor
CYPRUS
1. High blood pressure
2. High cholesterol
3. Tobacco
4. Low fruit and vegetable intake
5. Physical inactivity
6. High BMI
7. Urban outdoor air pollution
8. Alcohol
9. Iron deficiency
10. Unsafe sex
23.6
9.8
9.7
4.8
4.4
4.3
1.2
0.9
0.4
0.4
1. High blood pressure
2. Tobacco
3. High BMI
4. High cholesterol
5. Physical inactivity
6. Low fruit and vegetable intake
7. Iron deficiency
8. Lead
9. Alcohol
10. Unsafe sex
8.0
5.6
5.2
3.9
2.4
2.1
1.5
1.2
1.1
1.0
CZECH REPUBLIC
1. High blood pressure
2. Tobacco
3. High cholesterol
4. High BMI
5. Physical inactivity
6. Low fruit and vegetable intake
7. Unsafe sex
8. Urban outdoor air pollution
9. Occupational carcinogens
10. Illicit drugs
26.8
21.8
18.3
11.4
7.3
5.2
0.9
0.6
0.4
0.3
1. Tobacco
2. High blood pressure
3. High cholesterol
4. High BMI
5. Alcohol
6. Physical inactivity
7. Low fruit and vegetable intake
8. Unsafe sex
9. Illicit drugs
10. Iron deficiency
15.5
12.8
9.8
8.4
6.2
4.1
3.0
1.2
0.9
0.5
DENMARK
DALYs
% of
total
1. Tobacco
2. High blood pressure
3. High cholesterol
4. High BMI
5. Physical inactivity
6. Low fruit and vegetable intake
7. Occupational airborne particulate matter
8. Unsafe sex
9. Urban outdoor air pollution
10. Illicit drugs
25.7
11.8
11.5
8.4
5.1
3.4
0.8
0.8
0.5
0.4
1. Tobacco
2. Alcohol
3. High BMI
4. High cholesterol
5. High blood pressure
6. Physical inactivity
7. Low fruit and vegetable intake
8. Illicit drugs
9. Unsafe sex
10. Occupational airborne particulate matter
17.7
7.2
6.3
5.4
5.0
2.7
1.8
1.6
1.0
0.8
ESTONIA
Deaths
1. High blood pressure
2. High cholesterol
3. Tobacco
4. Low fruit and vegetable intake
5. High BMI
6. Alcohol
7. Physical inactivity
8. Urban outdoor air pollution
9. Lead
10. Unsafe sex
28.3
23.7
17.4
12.6
11.4
10.9
9.1
1.2
0.8
0.8
1. Alcohol
2. High blood pressure
3. Tobacco
4. High cholesterol
5. High BMI
6. Low fruit and vegetable intake
7. Physical inactivity
8. Illicit drugs
9. Unsafe sex
10. Lead
15.4
12.5
11.9
10.1
7.5
5.9
4.1
1.3
1.2
0.9
FINLAND
Member
State
Risk factor
% of
total
1. High blood pressure
2. High cholesterol
3. Tobacco
4. High BMI
5. Physical inactivity
6. Low fruit and vegetable intake
7. Urban outdoor air pollution
8. Illicit drugs
9. Unsafe sex
10. Occupational airborne particulate matter
22.0
17.3
13.9
8.9
6.3
4.5
0.6
0.5
0.5
0.4
1. High blood pressure
2. High cholesterol
3. Tobacco
4. Alcohol
5. High BMI
6. Physical inactivity
7. Low fruit and vegetable intake
8. Illicit drugs
9. Unsafe sex
10. Childhood sexual abuse
9.3
7.9
7.7
6.9
6.7
3.2
2.3
1.4
0.7
0.5
A N N E X TA B L E 5
Risk factor
% of
total
FRANCE
1. Tobacco
2. High blood pressure
3. High BMI
4. High cholesterol
5. Alcohol
6. Physical inactivity
7. Low fruit and vegetable intake
8. Unsafe sex
9. Occupational airborne particulate matter
10. Illicit drugs
16.2
12.8
6.5
6.4
4.6
3.3
2.3
0.8
0.5
0.4
1. Tobacco
2. Alcohol
3. High blood pressure
4. High BMI
5. High cholesterol
6. Physical inactivity
7. Illicit drugs
8. Low fruit and vegetable intake
9. Unsafe sex
10. Iron deficiency
12.4
10.7
4.9
4.7
3.1
1.8
1.5
1.3
1.0
0.5
GEORGIA
1. High blood pressure
2. High cholesterol
3. High BMI
4. Low fruit and vegetable intake
5. Physical inactivity
6. Tobacco
7. Alcohol
8. Urban outdoor air pollution
9. Lead
10. Unsafe sex
48.8
22.9
17.3
11.1
10.6
9.3
4.6
2.6
1.5
0.7
1. High blood pressure
2. High cholesterol
3. High BMI
4. Tobacco
5. Low fruit and vegetable intake
6. Alcohol
7. Physical inactivity
8. Illicit drugs
9. Unsafe sex
10. Lead
23.5
11.9
11.9
9.2
5.8
5.8
5.6
2.6
1.6
1.6
GERMANY
DALYs
% of
total
1. High blood pressure
2. Tobacco
3. High cholesterol
4. High BMI
5. Physical inactivity
6. Low fruit and vegetable intake
7. Unsafe sex
8. Urban outdoor air pollution
9. Occupational airborne particulate matter
10. Illicit drugs
25.9
18.3
15.1
9.9
5.9
4.1
0.7
0.6
0.4
0.4
1. Tobacco
2. High blood pressure
3. Alcohol
4. High cholesterol
5. High BMI
6. Physical inactivity
7. Low fruit and vegetable intake
8. Illicit drugs
9. Unsafe sex
10. Iron deficiency
13.7
11.2
7.5
7.2
7.1
3.2
2.2
1.7
0.8
0.5
GREECE
Deaths
1. High blood pressure
2. Tobacco
3. High cholesterol
4. High BMI
5. Physical inactivity
6. Low fruit and vegetable intake
7. Urban outdoor air pollution
8. Unsafe sex
9. Occupational carcinogens
10. Illicit drugs
25.0
19.3
11.6
8.3
5.0
3.9
0.6
0.5
0.4
0.3
1. Tobacco
2. High blood pressure
3. High BMI
4. High cholesterol
5. Alcohol
6. Physical inactivity
7. Low fruit and vegetable intake
8. Illicit drugs
9. Unsafe sex
10. Iron deficiency
12.9
11.8
8.5
7.6
4.3
3.5
2.6
1.7
0.8
0.5
HUNGARY
Member
State
Risk factor
111
1. Tobacco
2. High blood pressure
3. High cholesterol
4. Alcohol
5. High BMI
6. Low fruit and vegetable intake
7. Physical inactivity
8. Urban outdoor air pollution
9. Occupational carcinogens
10. Lead
26.3
26.0
17.2
11.4
11.1
10.3
7.5
1.1
0.9
0.8
1. Tobacco
2. Alcohol
3. High blood pressure
4. High cholesterol
5. High BMI
6. Low fruit and vegetable intake
7. Physical inactivity
8. Unsafe sex
9. Lead
10. Contaminated injections in health care settings
20.9
15.5
12.2
8.9
7.8
5.7
3.9
1.0
0.9
0.8
112
T H E E U R O P E A N H E A LT H R E P O R T 2 0 0 5
Table 5 contd
Risk factor
% of
total
ICELAND
1. Tobacco
2. High cholesterol
3. High blood pressure
4. High BMI
5. Physical inactivity
6. Low fruit and vegetable intake
7. Unsafe sex
8. Urban outdoor air pollution
9. Illicit drugs
10. Occupational airborne particulate matter
20.8
15.2
15.0
8.0
5.6
4.1
0.8
0.6
0.5
0.4
1. Tobacco
2. High cholesterol
3. High BMI
4. High blood pressure
5. Alcohol
6. Physical inactivity
7. Illicit drugs
8. Low fruit and vegetable intake
9. Unsafe sex
10. Iron deficiency
12.6
5.9
5.4
5.2
4.8
2.5
2.1
1.9
1.1
0.7
IRELAND
1. Tobacco
2. High blood pressure
3. High cholesterol
4. High BMI
5. Physical inactivity
6. Low fruit and vegetable intake
7. Illicit drugs
8. Occupational airborne particulate matter
9. Urban outdoor air pollution
10. Unsafe sex
23.2
18.0
14.4
8.4
5.6
4.1
0.6
0.6
0.6
0.5
1. Tobacco
2. Alcohol
3. High blood pressure
4. High cholesterol
5. High BMI
6. Physical inactivity
7. Illicit drugs
8. Low fruit and vegetable intake
9. Unsafe sex
10. Occupational airborne particulate matter
11.8
7.9
7.2
6.4
5.5
2.8
2.6
2.0
0.7
0.6
ISRAEL
DALYs
% of
total
1. High BMI
2. High blood pressure
3. Tobacco
4. High cholesterol
5. Physical inactivity
6. Low fruit and vegetable intake
7. Unsafe sex
8. Illicit drugs
9. Urban outdoor air pollution
10. Occupational airborne particulate matter
12.5
11.8
11.8
8.2
5.5
3.1
0.6
0.4
0.4
0.4
1. Tobacco
2. High BMI
3. High blood pressure
4. Alcohol
5. High cholesterol
6. Illicit drugs
7. Physical inactivity
8. Low fruit and vegetable intake
9. Unsafe sex
10. Iron deficiency
6.1
6.0
3.8
3.0
2.9
2.7
2.2
1.2
0.8
0.7
ITALY
Deaths
1. High blood pressure
2. Tobacco
3. High cholesterol
4. High BMI
5. Physical inactivity
6. Low fruit and vegetable intake
7. Unsafe sex
8. Alcohol
9. Urban outdoor air pollution
10. Occupational airborne particulate matter
21.7
18.8
11.1
10.0
5.0
3.5
0.6
0.6
0.6
0.5
1. Tobacco
2. High blood pressure
3. High BMI
4. Alcohol
5. High cholesterol
6. Physical inactivity
7. Illicit drugs
8. Low fruit and vegetable intake
9. Unsafe sex
10. Iron deficiency
12.0
8.9
8.4
5.9
5.7
3.1
2.2
2.0
1.1
0.6
KAZAKHSTAN
Member
State
Risk factor
1. High blood pressure
2. High cholesterol
3. Tobacco
4. High BMI
5. Low fruit and vegetable intake
6. Alcohol
7. Physical inactivity
8. Indoor smoke from solid-fuel use
9. Lead
10. Urban outdoor air pollution
29.3
21.5
19.1
12.5
11.8
10.9
8.0
1.5
1.2
1.1
1. Tobacco
2. Alcohol
3. High blood pressure
4. High cholesterol
5. High BMI
6. Low fruit and vegetable intake
7. Physical inactivity
8. Indoor smoke from solid-fuel use
9. Illicit drugs
10. Lead
13.4
12.8
12.3
9.6
7.4
5.5
3.5
1.7
1.4
1.2
A N N E X TA B L E 5
Risk factor
KYRGYZSTAN
1. High blood pressure
2. High cholesterol
3. High BMI
4. Tobacco
5. Low fruit and vegetable intake
6. Alcohol
7. Physical inactivity
8. Indoor smoke from solid-fuel use
9. Childhood and maternal underweight
10. Urban outdoor air pollution
19.5
14.1
11.4
10.7
7.0
6.9
6.4
5.2
2.1
1.9
1. Tobacco
2. Alcohol
3. High blood pressure
4. High BMI
5. High cholesterol
6. Indoor smoke from solid-fuel use
7. Childhood and maternal underweight
8. Low fruit and vegetable intake
9. Physical inactivity
10. Unsafe water, sanitation and hygiene
LATVIA
1. High blood pressure
2. High cholesterol
3. Tobacco
4. Low fruit and vegetable intake
5. High BMI
6. Alcohol
7. Physical inactivity
8. Urban outdoor air pollution
9. Unsafe sex
10. Lead
31.7
23.0
16.5
12.4
11.1
10.8
8.9
1.2
1.0
0.9
1. Alcohol
2. High blood pressure
3. Tobacco
4. High cholesterol
5. High BMI
6. Low fruit and vegetable intake
7. Physical inactivity
8. Illicit drugs
9. Unsafe sex
10. Lead
15.4
14.0
12.0
11.0
7.8
6.4
4.4
1.9
1.3
0.9
LITHUANIA
DALYs
% of
total
1. High blood pressure
2. High cholesterol
3. Tobacco
4. Low fruit and vegetable intake
5. Alcohol
6. High BMI
7. Physical inactivity
8. Urban outdoor air pollution
9. Unsafe sex
10. Lead
33.0
23.2
17.8
12.0
10.7
10.5
9.1
1.2
1.1
0.8
1. Alcohol
2. High blood pressure
3. Tobacco
4. High cholesterol
5. High BMI
6. Low fruit and vegetable intake
7. Physical inactivity
8. Unsafe sex
9. Lead
10. Illicit drugs
14.9
13.0
11.5
9.2
6.9
5.4
3.9
1.3
0.9
0.9
LUXEMBOURG
Deaths
1. Tobacco
2. High blood pressure
3. High cholesterol
4. High BMI
5. Physical inactivity
6. Low fruit and vegetable intake
7. Alcohol
8. Unsafe sex
9. Illicit drugs
10. Urban outdoor air pollution
17.7
15.2
10.7
7.9
4.5
3.2
3.1
0.6
0.5
0.5
1. Tobacco
2. Alcohol
3. High blood pressure
4. High BMI
5. High cholesterol
6. Physical inactivity
7. Illicit drugs
8. Low fruit and vegetable intake
9. Unsafe sex
10. Iron deficiency
11.3
10.8
6.0
5.6
5.1
2.3
2.2
1.6
0.8
0.6
MALTA
Member
State
Risk factor
113
% of
total
1. High blood pressure
2. High cholesterol
3. Tobacco
4. High BMI
5. Physical inactivity
6. Low fruit and vegetable intake
7. Unsafe sex
8. Urban outdoor air pollution
9. Occupational airborne particulate matter
10. Occupational carcinogens
25.0
19.9
15.4
11.7
7.2
4.9
0.6
0.6
0.4
0.3
1. High blood pressure
2. High BMI
3. Tobacco
4. High cholesterol
5. Physical inactivity
6. Alcohol
7. Low fruit and vegetable intake
8. Unsafe sex
9. Illicit drugs
10. Iron deficiency
11.0
9.8
9.7
9.4
4.1
3.0
2.5
0.9
0.9
0.6
6.6
6.4
6.1
5.4
5.3
4.6
3.2
2.6
2.4
2.0
114
T H E E U R O P E A N H E A LT H R E P O R T 2 0 0 5
Table 5 contd
Risk factor
% of
total
MONACO
1. Tobacco
2. High blood pressure
3. High cholesterol
4. High BMI
5. Physical inactivity
6. Low fruit and vegetable intake
7. Alcohol
8. Unsafe sex
9. Illicit drugs
10. Occupational airborne particulate matter
15.8
14.2
8.0
6.4
3.5
2.5
2.3
0.8
0.4
0.4
1. Tobacco
2. Alcohol
3. High BMI
4. High blood pressure
5. High cholesterol
6. Physical inactivity
7. Unsafe sex
8. Low fruit and vegetable intake
9. Illicit drugs
10. Iron deficiency
10.4
9.3
5.6
5.2
3.5
2.0
1.3
1.3
1.1
0.6
NETHERLANDS
1. Tobacco
2. High blood pressure
3. High cholesterol
4. High BMI
5. Physical inactivity
6. Low fruit and vegetable intake
7. Occupational airborne particulate matter
8. Unsafe sex
9. Urban outdoor air pollution
10. Occupational carcinogens
23.7
17.4
8.1
7.8
4.5
3.2
0.7
0.6
0.5
0.4
1. Tobacco
2. High blood pressure
3. High BMI
4. Alcohol
5. High cholesterol
6. Physical inactivity
7. Low fruit and vegetable intake
8. Illicit drugs
9. Unsafe sex
10. Occupational airborne particulate matter
16.7
7.8
6.1
5.0
4.7
2.7
1.9
1.8
0.9
0.6
NORWAY
DALYs
% of
total
1. High blood pressure
2. Tobacco
3. High cholesterol
4. High BMI
5. Physical inactivity
6. Low fruit and vegetable intake
7. Illicit drugs
8. Unsafe sex
9. Urban outdoor air pollution
10. Occupational airborne particulate matter
18.8
15.4
14.9
7.7
5.3
3.6
1.0
0.6
0.5
0.5
1. Tobacco
2. High blood pressure
3. High cholesterol
4. High BMI
5. Alcohol
6. Illicit drugs
7. Physical inactivity
8. Low fruit and vegetable intake
9. Unsafe sex
10. Iron deficiency
11.8
7.8
7.0
6.1
4.2
3.1
2.9
1.9
0.8
0.6
POLAND
Deaths
1. Tobacco
2. High blood pressure
3. High cholesterol
4. High BMI
5. Alcohol
6. Low fruit and vegetable intake
7. Physical inactivity
8. Urban outdoor air pollution
9. Unsafe sex
10. Lead
25.3
25.0
13.8
10.6
6.7
6.6
6.1
1.7
1.1
0.9
1. Tobacco
2. High blood pressure
3. Alcohol
4. High BMI
5. High cholesterol
6. Low fruit and vegetable intake
7. Physical inactivity
8. Unsafe sex
9. Illicit drugs
10. Lead
16.6
10.4
9.2
7.1
6.9
3.3
3.1
1.3
1.2
1.0
PORTUGAL
Member
State
Risk factor
1. High blood pressure
2. Tobacco
3. High cholesterol
4. High BMI
5. Physical inactivity
6. Low fruit and vegetable intake
7. Alcohol
8. Unsafe sex
9. Illicit drugs
10. Urban outdoor air pollution
23.0
12.1
10.7
10.2
5.0
3.6
3.1
1.6
0.9
0.5
1. High blood pressure
2. Tobacco
3. Alcohol
4. High BMI
5. High cholesterol
6. Illicit drugs
7. Physical inactivity
8. Unsafe sex
9. Low fruit and vegetable intake
10. Iron deficiency
10.5
10.4
8.5
7.9
6.1
3.3
2.9
2.5
2.1
0.5
A N N E X TA B L E 5
Risk factor
% of
total
REPUBLIC OF MOLDOVA
1. High blood pressure
2. High cholesterol
3. Alcohol
4. Low fruit and vegetable intake
5. High BMI
6. Tobacco
7. Physical inactivity
8. Indoor smoke from solid-fuel use
9. Urban outdoor air pollution
10. Contaminated injections in health care settings
33.3
27.3
17.4
14.1
13.1
12.5
10.3
1.8
1.3
1.2
1. Alcohol
2. High blood pressure
3. High cholesterol
4. Tobacco
5. High BMI
6. Low fruit and vegetable intake
7. Physical inactivity
8. Indoor smoke from solid-fuel use
9. Unsafe sex
10. Lead
20.8
13.1
10.6
9.7
7.6
5.9
4.2
1.6
1.2
1.0
ROMANIA
1. High blood pressure
2. Tobacco
3. High cholesterol
4. High BMI
5. Alcohol
6. Low fruit and vegetable intake
7. Physical inactivity
8. Urban outdoor air pollution
9. Lead
10. Unsafe sex
31.8
16.3
14.4
13.9
12.4
7.1
6.6
2.1
1.3
1.2
1. High blood pressure
2. Tobacco
3. Alcohol
4. High BMI
5. High cholesterol
6. Low fruit and vegetable intake
7. Physical inactivity
8. Unsafe sex
9. Lead
10. Indoor smoke from solid-fuel use
13.8
13.1
12.4
9.2
7.5
3.7
3.5
1.6
1.2
0.9
RUSSIAN FEDERATION
DALYs
% of
total
1. High blood pressure
2. High cholesterol
3. Tobacco
4. Low fruit and vegetable intake
5. High BMI
6. Alcohol
7. Physical inactivity
8. Urban outdoor air pollution
9. Lead
10. Illicit drugs
35.5
23.0
17.1
12.9
12.5
11.9
9.0
1.2
1.2
0.9
1. Alcohol
2. High blood pressure
3. Tobacco
4. High cholesterol
5. High BMI
6. Low fruit and vegetable intake
7. Physical inactivity
8. Illicit drugs
9. Lead
10. Unsafe sex
16.5
16.3
13.4
12.3
8.5
7.0
4.6
2.2
1.1
1.0
SAN MARINO
Deaths
1. High blood pressure
2. Tobacco
3. High cholesterol
4. High BMI
5. Physical inactivity
6. Low fruit and vegetable intake
7. Unsafe sex
8. Occupational carcinogens
9. Urban outdoor air pollution
10. Lead
22.2
22.0
11.2
5.8
4.2
3.6
0.7
0.5
0.5
0.1
1. Tobacco
2. High blood pressure
3. High BMI
4. High cholesterol
5. Alcohol
6. Physical inactivity
7. Low fruit and vegetable intake
8. Unsafe sex
9. Iron deficiency
10. Illicit drugs
11.0
9.8
6.8
6.4
4.7
2.9
2.2
1.0
0.6
0.4
SERBIA AND MONTENEGRO
Member
State
Risk factor
115
1. High blood pressure
2. Tobacco
3. High BMI
4. High cholesterol
5. Low fruit and vegetable intake
6. Physical inactivity
7. Alcohol
8. Urban outdoor air pollution
9. Lead
10. Indoor smoke from solid-fuel use
34.2
19.7
12.1
11.7
6.4
6.2
4.1
1.9
1.1
1.1
1. High blood pressure
2. Tobacco
3. High BMI
4. Alcohol
5. High cholesterol
6. Low fruit and vegetable intake
7. Physical inactivity
8. Lead
9. Unsafe sex
10. Illicit drugs
16.8
15.3
8.6
7.2
6.8
3.7
3.6
1.2
1.2
1.1
116
T H E E U R O P E A N H E A LT H R E P O R T 2 0 0 5
Table 5 contd
Risk factor
% of
total
SLOVAKIA
1. High blood pressure
2. Tobacco
3. High cholesterol
4. High BMI
5. Alcohol
6. Low fruit and vegetable intake
7. Physical inactivity
8. Urban outdoor air pollution
9. Lead
10. Unsafe sex
29.7
19.2
14.3
14.0
11.5
7.4
7.2
1.9
1.0
0.9
1. Alcohol
2. Tobacco
3. High blood pressure
4. High BMI
5. High cholesterol
6. Physical inactivity
7. Low fruit and vegetable intake
8. Illicit drugs
9. Unsafe sex
10. Lead
13.2
12.2
11.4
8.0
5.7
3.1
3.1
1.7
1.1
1.0
SLOVENIA
1. Tobacco
2. High blood pressure
3. High cholesterol
4. High BMI
5. Alcohol
6. Physical inactivity
7. Low fruit and vegetable intake
8. Unsafe sex
9. Urban outdoor air pollution
10. Occupational airborne particulate matter
19.7
17.8
12.1
10.0
6.5
5.1
3.6
0.8
0.5
0.5
1. Tobacco
2. Alcohol
3. High blood pressure
4. High BMI
5. High cholesterol
6. Physical inactivity
7. Low fruit and vegetable intake
8. Illicit drugs
9. Unsafe sex
10. Childhood sexual abuse
13.7
11.4
8.2
6.8
6.3
2.8
2.1
1.1
0.8
0.5
SPAIN
DALYs
% of
total
1. Tobacco
2. High blood pressure
3. High cholesterol
4. High BMI
5. Physical inactivity
6. Low fruit and vegetable intake
7. Unsafe sex
8. Alcohol
9. Occupational airborne particulate matter
10. Illicit drugs
16.8
15.6
8.9
7.9
4.2
3.0
0.8
0.8
0.7
0.6
1. Tobacco
2. Alcohol
3. High BMI
4. High blood pressure
5. High cholesterol
6. Illicit drugs
7. Physical inactivity
8. Low fruit and vegetable intake
9. Unsafe sex
10. Iron deficiency
12.3
7.6
6.4
5.8
4.5
3.9
2.5
1.7
1.4
0.6
SWEDEN
Deaths
1. High blood pressure
2. High cholesterol
3. Tobacco
4. High BMI
5. Physical inactivity
6. Low fruit and vegetable intake
7. Unsafe sex
8. Urban outdoor air pollution
9. Occupational airborne particulate matter
10. Illicit drugs
25.2
14.5
10.8
8.4
5.7
3.8
0.6
0.5
0.3
0.3
1. High blood pressure
2. Tobacco
3. High cholesterol
4. High BMI
5. Alcohol
6. Physical inactivity
7. Low fruit and vegetable intake
8. Illicit drugs
9. Unsafe sex
10. Iron deficiency
10.5
8.0
7.1
6.8
4.2
3.2
2.1
1.2
0.8
0.6
SWITZERLAND
Member
State
Risk factor
1. High blood pressure
2. High cholesterol
3. Tobacco
4. High BMI
5. Physical inactivity
6. Low fruit and vegetable intake
7. Unsafe sex
8. Urban outdoor air pollution
9. Occupational airborne particulate matter
10. Illicit drugs
25.2
14.5
10.8
8.4
5.7
3.8
0.6
0.5
0.3
0.3
1. Tobacco
2. Alcohol
3. High blood pressure
4. High BMI
5. High cholesterol
6. Illicit drugs
7. Physical inactivity
8. Low fruit and vegetable intake
9. Unsafe sex
10. Childhood sexual abuse
10.7
7.2
6.3
6.0
4.9
2.7
2.4
1.7
1.0
0.6
A N N E X TA B L E 5
1. High blood pressure
2. High BMI
3. High cholesterol
4. Alcohol
5. Low fruit and vegetable intake
6. Physical inactivity
7. Indoor smoke from solid-fuel use
8. Unsafe water, sanitation and hygiene
9. Tobacco
10. Childhood and maternal underweight
21.4
13.7
10.5
6.1
5.3
4.9
3.4
3.2
3.0
2.5
1. High blood pressure
2. High BMI
3. Alcohol
4. Unsafe water, sanitation and hygiene
5. Indoor smoke from solid-fuel use
6. Childhood and maternal underweight
7. High cholesterol
8. Tobacco
9. Iron deficiency
10. Low fruit and vegetable intake
1. High blood pressure
2. Tobacco
3. High BMI
4. High cholesterol
5. Low fruit and vegetable intake
6. Physical inactivity
7. Alcohol
8. Urban outdoor air pollution
9. Lead
10. Indoor smoke from solid-fuel use
23.6
15.9
11.8
9.4
5.3
5.1
3.9
2.1
1.0
0.7
1. Tobacco
2. High blood pressure
3. High BMI
4. Alcohol
5. High cholesterol
6. Low fruit and vegetable intake
7. Physical inactivity
8. Unsafe sex
9. Lead
10. Illicit drugs
1. High blood pressure
2. Tobacco
3. High BMI
4. High cholesterol
5. Low fruit and vegetable intake
6. Physical inactivity
7. Alcohol
8. Urban outdoor air pollution
9. Childhood and maternal underweight
10. Unsafe water, sanitation and hygiene
20.7
11.8
11.6
10.5
6.7
6.2
4.3
1.8
1.4
1.4
1. Tobacco
2. High blood pressure
3. High BMI
4. Alcohol
5. High cholesterol
6. Low fruit and vegetable intake
7. Physical inactivity
8. Childhood and maternal underweight
9. Unsafe water, sanitation and hygiene
10. Lead
7.0
6.1
5.8
4.3
4.2
2.5
2.4
2.1
1.8
1.3
1. High blood pressure
2. High BMI
3. High cholesterol
4. Alcohol
5. Tobacco
6. Low fruit and vegetable intake
7. Physical inactivity
8. Childhood and maternal underweight
9. Indoor smoke from solid-fuel use
10. Unsafe water, sanitation and hygiene
22.8
16.5
14.1
7.7
6.9
6.8
6.4
3.1
2.9
2.3
1. High BMI
2. High blood pressure
3. Alcohol
4. High cholesterol
5. Tobacco
6. Childhood and maternal underweight
7. Indoor smoke from solid-fuel use
8. Unsafe water, sanitation and hygiene
9. Low fruit and vegetable intake
10. Physical inactivity
7.4
7.1
6.0
5.5
5.1
4.4
3.6
3.1
2.7
2.5
1. High blood pressure
2. High cholesterol
3. Low fruit and vegetable intake
4. Tobacco
5. High BMI
6. Physical inactivity
7. Alcohol
8. Illicit drugs
9. Urban outdoor air pollution
10. Indoor smoke from solid-fuel use
36.3
29.9
15.5
14.8
13.2
11.2
9.2
1.4
1.4
1.3
1. High blood pressure
2. High cholesterol
3. Tobacco
4. Alcohol
5. High BMI
6. Low fruit and vegetable intake
7. Physical inactivity
8. Illicit drugs
9. Unsafe sex
10. Indoor smoke from solid-fuel use
THE FORMER YUGOSLAV
REPUBLIC OF MACEDONIA
TAJIKISTAN
Risk factor
TURKEY
DALYs
% of
total
TURKMENISTAN
Deaths
UKRAINE
Member
State
Risk factor
117
% of
total
5.8
5.4
4.8
4.3
4.2
4.0
3.5
2.3
2.1
1.8
11.1
10.8
7.6
5.4
5.4
3.0
2.9
1.2
1.2
1.0
16.6
14.4
12.8
12.3
9.0
8.0
5.6
3.0
1.6
1.1
118
T H E E U R O P E A N H E A LT H R E P O R T 2 0 0 5
Table 5 contd
DALYs
% of
total
Risk factor
% of
total
UNITED KINGDOM
Deaths
1. Tobacco
2. High blood pressure
3. High cholesterol
4. High BMI
5. Physical inactivity
6. Low fruit and vegetable intake
7. Occupational airborne particulate matter
8. Urban outdoor air pollution
9. Unsafe sex
10. Illicit drugs
24.3
19.4
13.3
8.0
5.5
4.0
0.6
0.6
0.6
0.4
1. Tobacco
2. High blood pressure
3. High cholesterol
4. High BMI
5. Alcohol
6. Physical inactivity
7. Illicit drugs
8. Low fruit and vegetable intake
9. Unsafe sex
10. Occupational airborne particulate matter
14.2
8.6
6.9
6.3
5.2
3.1
2.6
2.2
0.8
0.6
UZBEKISTAN
Member
State
Risk factor
1. High blood pressure
2. High cholesterol
3. High BMI
4. Low fruit and vegetable intake
5. Physical inactivity
6. Alcohol
7. Tobacco
8. Indoor smoke from solid-fuel use
9. Childhood and maternal underweight
10. Urban outdoor air pollution
20.0
16.7
15.0
8.1
7.7
5.3
4.1
3.3
2.3
2.1
1. High BMI
2. High blood pressure
3. High cholesterol
4. Alcohol
5. Indoor smoke from solid-fuel use
6. Childhood and maternal underweight
7. Tobacco
8. Low fruit and vegetable intake
9. Physical inactivity
10. Iron deficiency
6.4
6.1
5.4
4.7
3.9
3.7
3.1
2.6
2.5
2.3
A N N E X TA B L E 6
119
Table 6. Basic indicators of the status and determinants of child health in the WHO European Region, 2002 or latest available yeara
Health status
Member State
Albania
Andorra
Armenia
Austria
Azerbaijan
Belarus
Belgium
Bosnia and Herzegovina
Bulgaria
Croatia
Cyprus
Czech Republic
Denmark
Estonia
Finland
France
Georgia
Germany
Greece
Hungary
Iceland
Ireland
Israel
Italy
Kazakhstan
Kyrgyzstan
Latvia
Lithuania
Luxembourg
Malta
Monaco
Netherlands
Norway
Poland
Portugal
Republic of Moldova
Romania
Russian Federation
San Marino
Serbia and Montenegro
Slovakia
Slovenia
Spain
Sweden
Switzerland
Tajikistan
TFYR of Macedoniab
Turkey
Turkmenistan
Ukraine
United Kingdom
Uzbekistan
a
b
Mortality from all causes
in children aged (years):
0–1
1–4
5–14 1–19
1157.7
–
1285.2
411.8
1286.3
911.5
560.1
1525.1
1349.4
698.0
–
419.8
413.7
580.9
296.5
441.8
1187.7
421.2
618.2
728.5
238.6
600.9
587.0
451.0
1715.5
2175.8
992.8
778.6
390.7
588.7
–
518.0
396.9
754.5
565.0
1472.8
1747.4
1375.3
0.0
1336.2
627.2
383.6
450.7
367.4
492.6
1419.7
1370.7
–
3085.0
1110.6
571.2
1837.5
114.3
–
52.6
19.6
248.0
62.2
25.9
42.2
67.2
29.1
–
28.0
21.7
49.0
16.1
24.7
38.5
25.3
27.0
36.3
0.0
35.8
35.2
18.9
127.4
197.5
84.2
52.8
30.8
28.4
–
28.1
21.2
31.3
42.6
77.2
82.6
85.5
0.0
61.0
43.9
26.3
26.1
18.9
22.1
187.1
46.7
–
533.0
79.7
27.2
206.0
39.5 62.5
–
–
16.3 31.8
11.3 23.5
45.3 94.6
28.3 49.8
14.9 26.5
27.4 41.8
26.4 40.9
12.4 25.8
–
–
15.1 26.4
17.6 25.9
27.3 48.3
12.1 21.9
14.3 26.0
20.7 35.7
12.3 23.1
15.3 29.1
18.9 28.3
20.2 22.0
14.2 29.1
16.0 24.2
13.7 21.9
46.8 80.8
43.3 86.4
31.8 56.7
27.0 48.1
12.7 28.0
11.0 20.3
–
–
13.4 23.4
9.4 22.8
18.7 29.4
22.8 38.4
38.4 54.8
44.6 54.8
43.6 75.7
0.0 38.0
23.3 37.7
22.8 33.1
13.7 27.0
16.3 26.1
10.2 17.3
13.9 22.2
41.3 80.1
21.9 32.6
–
–
64.2 183.6
36.9 58.5
13.0 23.8
43.8 89.4
Mortality from specific causes,
1–19
Infectious Congenital Cancer Accidents
diseases anomalies
1.9
–
1.8
0.5
7.4
1.8
0.9
0.4
1.1
0.6
–
0.5
0.8
0.2
0.4
0.5
1.6
0.8
0.7
0.7
1.2
0.8
0.6
0.3
3.8
8.5
2.4
0.9
1.0
1.0
–
0.9
0.8
0.7
2.1
2.0
5.7
2.5
0.0
2.7
0.5
0.6
1.3
0.2
0.8
14.6
1.5
–
24.5
2.1
1.3
5.8
1.4
–
3.1
2.1
1.5
3.9
1.1
2.1
2.9
2.6
–
1.5
3.9
2.4
0.7
1.2
0.0
1.7
3.1
3.0
0.0
2.2
1.7
1.4
5.0
4.0
4.8
3.6
1.0
2.7
–
1.4
2.0
2.4
2.1
5.1
3.9
4.8
0.0
3.1
2.1
3.3
2.0
1.5
1.8
2.1
0.7
–
2.6
5.2
1.7
2.1
4.3
–
5.7
2.4
7.0
4.3
4.2
3.7
4.5
4.6
–
3.2
3.7
6.3
3.3
3.0
2.4
3.0
4.4
4.4
5.6
3.0
3.0
4.3
5.6
3.2
5.1
5.3
2.0
6.4
–
3.6
2.2
4.5
4.3
7.2
6.7
5.5
19.0
3.8
5.1
3.6
3.7
3.3
3.0
2.3
3.8
–
5.1
6.4
3.3
4.2
16.3
–
8.0
9.3
11.6
24.0
11.0
9.2
11.7
10.1
–
11.2
10.1
22.7
9.2
11.5
3.8
8.2
15.4
9.4
7.0
10.9
7.1
8.2
27.2
21.0
29.3
21.2
13.1
4.9
–
7.2
7.7
10.8
8.3
23.7
19.9
33.3
19.0
7.6
13.1
9.3
11.5
5.9
8.0
12.6
10.4
–
34.2
23.0
6.3
21.3
Morbidity
Incidence of:
cancer,
insulinmeasles, all
ages (annual dependent 0–14
diabetes,
average,
0–14
1998–2002)
20.5
3.8
1.2
–
22.6
1.5
–
20.6
0.4
3.1
–
0.1
0.3
0.6
0.0
41.3
3.0
–
0.4
0.1
0.0
12.8
0.3
9.4
4.9
12.4
0.0
1.0
0.4
0.8
–
4.3
0.1
1.3
0.5
32.9
8.8
2.9
0.9
2.5
2.0
0.1
0.5
0.2
11.6
14.5
2.2
29.9
7.0
13.0
0.2
1.8
Figures were compiled by WHO to ensure comparability. All rates are per 100 000 of the relevant population, unless otherwise specified.
The former Yugoslav Republic of Macedonia.
3.6
12.8
–
9.5
1.2
5.7
11.8
3.5
8.8
6.6
10.5
9.8
19.4
11.4
37.4
8.3
8.1
12.2
9.1
9.6
13.9
16.3
5.9
9.5
1.2
1.2
7.1
7.8
11.9
–
–
13.0
22.5
6.7
11.5
5.0
5.0
7.2
9.5
8.1
9.2
8.5
12.8
28.0
7.9
1.2
3.6
3.2
1.2
8.1
18.9
1.2
–
–
–
–
–
154.4
–
–
102.7
–
–
124.9
149.7
126.2
154.7
135.6
–
128.7
–
119.6
129.2
133.2
–
158.0
–
–
–
127.7
–
148.7
–
137.5
139.5
106.5
139.4
–
101.8
–
–
119.4
131.5
119.1
137.9
154.3
146.9
–
–
115.6
–
–
121.0
–
Prevalence
of asthma
at age
13–14 (%)
2.6
–
–
11.6
–
–
12.0
–
–
–
–
–
–
10.8
16.0
13.5
3.6
13.8
3.7
–
–
29.1
–
8.9
–
–
8.4
–
–
16.0
–
–
–
8.1
9.5
–
3.0
4.4
–
–
–
–
10.3
12.9
–
–
–
–
–
–
32.2
9.2
120
T H E E U R O P E A N H E A LT H R E P O R T 2 0 0 5
Table 6 contd
Health determinants
Health and well-being (%)
Member State
Albania
Andorra
Armenia
Austria
Azerbaijan
Belarus
Belgium
Bosnia and Herzegovina
Bulgaria
Croatia
Cyprus
Czech Republic
Denmark
Estonia
Finland
France
Georgia
Germany
Greece
Hungary
Iceland
Ireland
Israel
Italy
Kazakhstan
Kyrgyzstan
Latvia
Lithuania
Luxembourg
Malta
Monaco
Netherlands
Norway
Poland
Portugal
Republic of Moldova
Romania
Russian Federation
San Marino
Serbia and Montenegro
Slovakia
Slovenia
Spain
Sweden
Switzerland
Tajikistan
TFYR Macedoniab
Turkey
Turkmenistan
Ukraine
United Kingdom
Uzbekistan
b
High life
satisfaction,
15
–
–
–
86.8
–
–
84.6
–
–
72.4
–
83.0
88.1
69.6
89.3
81.0
–
85.7
88.6
79.9
–
83.2
84.8
81.8
–
–
74.7
71.4
–
78.0
–
92.5
78.8
72.3
73.8
–
–
72.1
–
–
–
82.0
84.8
80.3
88.7
–
86.9
–
–
–
81.4
–
Children
in relative
poverty,
0–17
–
–
–
10.2
–
–
7.7
–
–
–
–
6.8
2.4
–
2.8
7.5
–
10.2
12.4
8.8
–
15.7
–
16.6
–
–
–
–
9.1
–
–
9.8
3.4
12.7
15.6
–
–
–
–
–
–
–
13.3
4.2
6.8
–
–
–
–
–
15.4
–
Low socioeconomic
status,
11–15
–
–
–
16.8
–
–
19.1
–
–
43.5
–
40.2
13.5
40.1
17.8
16.1
–
16.4
28.7
38.7
–
20.7
27.5
26.0
–
–
55.9
53.1
–
43.1
–
9.0
5.8
43.1
28.9
–
–
58.3
–
–
–
20.5
22.4
9.2
13.1
–
42.7
–
–
–
15.7
–
Socioeconomic determinants
Living in
a singleparent
family,
1–15
–
–
–
12.5
–
–
11.7
–
–
7.4
–
13.4
16.5
17.7
14.6
11.0
–
12.8
7.5
13.4
–
10.3
9.3
7.0
–
–
18.6
13.5
–
4.8
–
10.7
16.2
10.2
9.8
–
–
16.9
–
–
–
8.7
9.1
16.8
12.5
–
6.7
–
–
–
16.8
–
Expected
years of
schooling
At least
partially
breastfed
infants
aged 6
months (%)
10.9
–
8.5
14.8
10.5
12.2
16.0
–
12.7
11.9
13.0
13.6
15.0
14.4
16.7
15.4
6.4
15.3
14.9
13.6
16.0
14.9
14.8
14.9
11.7
–
13.3
14.2
13.1
14.0
–
16.0
16.9
14.7
–
9.7
11.7
–
–
10.3
13.1
15.0
15.5
15.9
15.1
9.9
–
9.5
–
11.4
16.3
–
87.0
–
63.0
–
30.4
50.5
–
–
–
17.1
–
31.7
–
42.1
51.0
–
44.2
–
–
48.3
67.2
–
41.0
37.8
71.5
79.1
26.4
26.6
–
–
–
25.0
80.0
–
–
81.0
38.9
32.6
–
32.0
36.8
–
40.0
72.4
–
72.3
40.3
71.4
–
41.4
21.0
95.5
Good Exposure to
parental household
support, tobacco
smoke,
15
under 5
(%)
(%)
–
–
–
72.8
–
–
68.4
–
–
82.4
–
74.6
72.0
71.2
78.6
78.9
–
75.3
72.6
86.4
–
73.5
77.7
73.0
–
–
75.9
69.9
–
74.5
–
87.1
75.0
86.4
79.1
–
–
79.7
–
–
–
88.7
79.0
81.9
77.5
–
90.4
–
–
–
79.4
–
The former Yugoslav Republic of Macedonia.
c
Estimates derived by regression and similar estimation methods.
Source: data from a wide array of publications and databases of WHO and other specialized agencies of the United Nations, and from Diabetes atlas, 2nd ed. Brussels,
International Diabetes Federation 2003 (http://www.eatlas.idf.org, accessed 25 May 2005).
–
–
–
–
–
–
–
68.6
–
–
–
54.0
–
59.2
–
–
73.0
–
–
–
–
–
–
–
–
–
63.6
62.9
–
–
–
–
–
67.2
–
–
–
62.9
–
65.0
54.5
47.7
–
–
–
–
–
–
–
58.9
–
–
A N N E X TA B L E 5
Family determinants
Lifestyle determinants in 15-year-olds (%)
Assault:
estimated
annual
incidence of
bone fracture,
0–14
Fair or
poor
health
at age
15
(%)
Suicide
rates,
0–14
DALYs
per 1000
children,
0–14
Tobacco
smoking
–
–
–
400.0
–
–
–
–
–
–
–
–
90.0
–
300.0
–
–
450.0
–
–
80.0
–
230.0
–
–
–
–
–
–
70.0
–
–
–
30.0
–
–
–
–
–
–
240.0
260.0
–
310.0
–
–
–
–
–
–
430.0
–
–
–
–
18.2
–
–
20.0
–
–
29.0
–
12.1
17.5
21.7
14.2
–
–
17.2
12.2
19.3
–
18.5
13.4
18.5
–
–
34.7
35.8
–
24.7
–
22.5
23.9
18.9
22.9
–
–
36.7
–
–
–
17.2
13.8
17.6
10.4
–
13.3
–
–
–
26.5
–
0.8
–
0.1
0.3
0.2
0.7
–
–
0.6
0.0
–
0.3
0.3
1.7
0.3
0.4
0.1
0.3
0.2
0.4
0.0
0.2
0.3
0.2
1.8
1.0
0.7
0.6
0.0
0.0
–
0.2
0.0
0.5
0.4
0.5
1.0
1.3
0.0
0.4
0.2
0.3
0.2
0.3
0.3
0.2
0.2
–
1.0
0.7
0.1
0.7
129.8
47.9
108.8
39.7
196.1
73.9
47.0
86.7
73.6
57.5
65.8
40.4
49.7
64.3
44.4
48.9
84.8
40.1
44.3
59.3
39.0
58.8
57.6
42.6
134.4
217.2
70.8
73.4
48.2
46.6
58.8
48.1
42.7
55.7
51.8
113.7
99.9
100.5
36.8
74.6
58.7
45.6
42.7
35.9
44.1
223.8
78.0
158.7
200.4
95.9
49.4
132.9
–
–
–
22.1
–
–
18.6
–
–
16.9
–
21.6
14.8
17.3
22.7
19.8
–
27.5
9.9
19.1
13.6
15.8
9.7
16.1
–
–
17.6
19.1
–
8.5
–
19.2
17.8
16.3
16.5
–
–
15.8
–
–
–
22.9
20.1
9.8
17.1
–
9.8
–
–
–
17.7
–
Alcohol Canabis Overweight
use
use
–
–
–
34.5
–
–
35.3
–
–
29.6
–
28.9
46.5
23.7
16.8
16.8
–
39.3
27.5
24.4
–
17.4
18.1
37.1
–
–
16.7
–
–
47.3
–
51.4
19.7
19.2
15.5
–
–
21.6
–
–
–
34.3
28.3
20.1
33.5
–
18.2
–
–
–
51.4
–
–
–
–
11.6
–
–
22.5
–
–
13.9
–
26.9
21.2
14.3
7.4
27.4
–
18.3
4.1
11.8
–
18.5
6.7
20.1
–
–
7.6
6.1
–
5.9
–
21.6
–
14.8
19.4
–
–
8.3
–
–
–
24.4
30.8
4.7
37.9
–
3.1
–
–
–
33.8
–
–
–
–
10.8
–
–
10.6
–
–
10.4
–
9.2
11.7
6.9
13.2
11.0
–
11.1
15.6
11.6
–
11.9
10.3
13.0
–
–
6.1
4.1
–
22.4
–
8.9
12.0
6.6
11.7
–
–
4.8
–
–
–
12.9
15.2
15.2
9.1
–
10.1
–
–
–
14.5
–
121
Health care determinants
Early neonatal One-year-olds
deaths per immunized with
hepatitis B3 (%)
1000 live
births, 2000
9c
3c
13
2
27c
3
2
9
5
4
3c
2
3
4
2
2
19c
2
3
5
2
3
3
2
29
26
5
3
3
4
2c
3
2
4
3
16
6
7
2c
7
4
3
2
2
3
29 c
7
19
26
9
3
21
97
84
93
44
98
99
50
–
96
–
88
86
–
–
–
29
49
81
88
–
–
–
98
97
99
99
98
95
49
70
99
–
–
97
94
99
98
94
96
–
99
–
83
–
–
57
–
68
97
77
–
99
Oral health
(DMFT) at
age 12
Leukaemia
survival
(%),
0–14
3.0
–
–
1.0
–
2.7
1.6
6.1
4.4
3.5
–
2.5
0.9
2.4
1.2
1.9
–
1.2
2.2
–
1.5
1.2
1.7
–
–
–
3.5
2.4
0.7
–
–
0.8
1.5
3.8
3.0
–
7.3
–
–
3.3
4.3
1.8
1.1
1.1
0.9
–
3.0
–
–
–
0.9
0.9
–
–
–
–
–
54.0
–
–
50.0
–
–
72.2
64.0
50.0
53.0
69.0
–
88.0
–
54.0
84.0
79.0
90.0
64.0
–
–
50.0
33.0
–
64.0
–
71.0
58.0
62.0
57.0
–
28.0
–
–
–
49.0
70.0
59.0
88.7
64.0
–
–
–
–
–
78.4
–
122
T H E E U R O P E A N H E A LT H R E P O R T 2 0 0 5
Table 7. Burden of disease from seven leading conditions in children aged 0–14 years (DALYs per 1000)
in the WHO European Region, 2002
Member State
Albania
Andorra
Armenia
Austria
Azerbaijan
Belarus
Belgium
Bosnia and Herzegovina
Bulgaria
Croatia
Cyprus
Czech Republic
Denmark
Estonia
Finland
France
Georgia
Germany
Greece
Hungary
Iceland
Ireland
Israel
Italy
Kazakhstan
Kyrgyzstan
Latvia
Lithuania
Luxembourg
Malta
Monaco
Netherlands
Norway
Poland
Portugal
Republic of Moldova
Romania
Russian Federation
San Marino
Serbia and Montenegro
Slovakia
Slovenia
Spain
Sweden
Switzerland
Tajikistan
TFYR Macedoniaa
Turkey
Turkmenistan
Ukraine
United Kingdom
Uzbekistan
European Region
1.
Neonatal
morbidity
12.5
5.7
23.4
4.3
22.6
3.6
3.7
17.9
5.6
9.0
6.8
3.8
5.2
4.6
1.8
4.2
32.4
4.8
6.8
7.2
4.6
5.9
7.7
6.3
16.8
41.6
6.7
2.0
7.4
6.3
4.3
4.9
2.5
5.3
5.3
11.9
8.4
7.8
2.1
14.9
5.1
3.0
4.0
1.5
3.6
40.2
19.2
31.1
18.6
8.1
7.2
19.4
11.8
2.
Respiratory
infections
15.9
0.5
8.0
0.2
56.4
1.2
0.3
1.5
5.1
0.6
4.7
0.9
0.2
0.4
0.4
0.3
7.1
0.2
0.6
0.6
0.4
0.7
0.4
0.3
20.6
42.3
0.8
1.4
0.1
0.2
0.2
0.4
0.3
0.6
0.7
9.2
13.7
2.1
0.0
3.9
1.5
0.4
0.3
0.2
0.2
38.1
2.0
15.1
59.1
1.5
0.6
32.8
7.4
3.
Major
congenital
anomalies
4.4
5.6
13.4
2.8
4.9
8.5
4.6
3.1
4.4
6.2
2.5
2.2
5.5
6.1
4.1
4.3
1.7
3.3
4.9
6.5
3.8
7.2
6.2
4.1
10.9
14.1
7.8
7.4
2.5
4.1
5.9
4.6
4.2
3.9
4.1
13.3
7.6
8.4
2.7
4.3
3.3
3.8
4.5
4.0
5.0
5.4
4.1
9.5
5.0
9.4
3.9
5.2
6.3
4.
Neuropsychiatric
disorders
5.
Iodine
deficiency
6.
Unintentional
injuries
7.
Asthma
Total,
columns
1–7
6.0
6.2
6.2
7.5
6.4
6.6
7.9
6.2
6.1
7.3
5.1
6.8
7.4
6.5
8.3
7.6
6.0
6.8
5.5
6.6
6.8
6.7
7.8
6.1
3.7
3.5
6.6
6.6
7.5
6.0
8.4
6.4
7.0
6.0
5.8
6.5
5.9
6.4
5.8
6.0
6.1
7.7
5.4
7.5
7.4
3.4
6.0
3.5
3.6
6.6
6.8
6.2
6.0
10.2
0.0
0.6
0.0
1.6
5.5
0.0
5.4
6.1
0.1
0.0
0.0
0.1
1.7
0.0
0.0
4.3
0.1
0.1
2.0
0.0
0.1
0.0
0.1
5.6
1.7
1.6
8.9
0.0
0.0
0.0
0.0
0.0
1.0
0.1
10.0
2.1
10.9
0.0
0.9
1.5
0.1
0.1
0.0
0.0
1.7
0.0
8.0
0.2
12.2
0.0
1.2
3.8
4.4
2.7
3.7
1.1
2.6
7.6
1.5
2.0
3.7
2.9
3.9
2.8
2.8
5.5
2.9
3.3
1.4
1.8
2.9
3.5
1.8
1.3
1.2
1.1
3.0
9.5
8.5
6.8
3.1
1.9
1.5
1.0
1.2
4.7
1.9
9.2
5.7
7.6
0.9
1.8
2.8
2.7
1.5
0.8
2.3
5.3
2.2
3.0
8.1
6.9
1.7
6.6
3.3
1.8
3.3
2.5
2.7
2.8
1.2
3.0
2.1
2.0
3.6
2.5
3.5
3.7
3.1
4.4
3.3
2.3
3.1
2.0
1.3
2.4
5.9
3.5
2.7
1.2
2.7
2.1
1.3
3.7
4.2
4.6
4.7
3.7
2.7
3.9
1.2
1.0
1.2
3.3
2.1
2.1
3.4
2.8
3.1
3.1
2.7
2.2
2.5
2.9
1.2
5.8
2.7
1.9
55.1
23.8
57.7
18.6
97.3
34.1
21.0
38.3
33.1
29.7
25.5
20.0
24.9
27.8
21.9
23.0
55.1
20.1
22.9
27.6
19.8
27.7
26.8
20.7
61.7
115.5
34.1
34.4
24.3
22.7
24.9
22.0
18.8
24.2
21.8
61.3
44.4
44.3
14.8
33.9
22.4
21.1
18.4
17.1
21.7
96.9
35.7
72.6
97.5
46.0
26.1
74.1
40.4
a
The former Yugoslav Republic of Macedonia.
Note. 1 = low birth weight, birth asphyxia and birth trauma; 2 = lower and upper respiratory infections; 3 = congenital heart anomalies, Down’s syndrome
and spina bifida; 4 = unipolar depressive disorders, schizophrenia and migraine; 6 = falls, road-traffic accidents and drownings.
Source: data from Mathers C et al. Global burden of disease in 2002: data sources, methods and results. Geneva, World Health Organization, 2004 (http://www3.who.
int/whosis/menu.cfm?path=evidence,burden,burden_gbd2000docs,burden_gbd2000docs_DP54&language=english, accessed 25 May 2005).
All
causes
129.8
47.9
108.8
39.7
196.1
73.9
47.0
86.7
73.6
57.5
65.8
40.4
49.7
64.3
44.4
48.9
84.8
40.1
44.3
59.3
39.0
58.8
57.6
42.6
134.4
217.2
70.8
73.4
48.2
46.6
58.8
48.1
42.7
55.7
51.8
113.7
99.9
100.5
36.8
74.6
58.7
45.6
42.7
35.9
44.1
223.8
78.0
158.7
200.4
95.9
49.4
132.9
89.6
ANNEX. DEFINITIONS
Definitions of the indicators included
in the tables
Adult mortality rate
Probability of dying (per 1000 population) between the ages of 15 and 60 years.
Source: World health statistics 2005. Indicators [online database]. Geneva, World Health
Organization, 2005 (http://www3.who.int/statistics/compendium.htm#adultmortality,
accessed 15 June 2005).
Alcohol use
Percentage of 15-year-olds who report that they drink alcohol (beer, wine or spirits) every week.
Source: Currie C et al., eds. Young people’s health in context. Health Behaviour in School-aged
Children (HBSC) study: international report from the 2001/2002 survey. Copenhagen, WHO
Regional Office for Europe, 2004 (Health Policy for Children and Adolescents, No. 4; http://
www.euro.who.int/eprise/main/who/informationsources/publications/catalogue/20040518_1,
accessed 25 May 2005).
Assault: estimated annual incidence of bone fracture
Annual number of hospital admissions per 100 000 children aged 0–14 years for the following
fractures: fractures of humerus; multiple fractures of clavicle, scapula and humerus; fractures
of shoulder and upper arm; fractures of forearm (radius and ulna); fractures of femur (all parts
of femur); fracture of lower leg (tibia and fibula) including ankle; multiple injuries that include
fractures to the above bones.
Source: Rigby M, Köhler L, eds. Child health indicators of life and development (CHILD). Report
to the European Commission. Luxembourg, Directorate-General for Health and Consumer
Protection, 2002 (http://www.ggd.nl/kennisnet/uploaddb/downl_object.asp?atoom=15443&V
olgNr=1, accessed 15 June 2005).
Cannabis use
Percentage of 15-year-olds who report that they have ever used cannabis and have used it within
the previous 12 months.
Source: Currie C et al., eds. Young people’s health in context. Health Behaviour in School-aged
Children (HBSC) study: international report from the 2001/2002 survey. Copenhagen, WHO
Regional Office for Europe, 2004 (Health Policy for Children and Adolescents, No. 4; http://
www.euro.who.int/eprise/main/who/informationsources/publications/catalogue/20040518_1,
accessed 25 May 2005).
Children living in relative poverty
Children living in households with income below 50% of the national median income.
Source: UNICEF Innocenti Research Centre. Child poverty in rich countries 2005. Florence,
United Nations Children’s Fund (Report Card No. 6; http://www.unicef-icdc.org/publications/
pdf/repcard6e.pdf, accessed 25 May 2005).
123
124
T H E E U R O P E A N H E A LT H R E P O R T 2 0 0 5
Coverage of registration of deaths
Percentage of estimated total deaths that are counted through vital registration system.
Source: World health statistics 2005. Indicators [online database]. Geneva, World Health
Organization, 2005 (http://www3.who.int/statistics/compendium.htm#registereddeathcoverag
e, accessed 15 June 2005).
Early neonatal mortality
Number of deaths of live-born infants during the first week of life per 1000 live births.
Source: Statistical annex. Explanatory notes. In: The world health report 2005 – Make every
mother and child count. Geneva, World Health Organization, 2005 (http://www.who.int/
whr/2005/10_annexes_notes_en.pdf, accessed 15 June 2005).
Expected years of schooling
The total number of years of schooling that a child can expect to receive, assuming that the
probability of his or her being enrolled in school at any particular future age is equal to the
current enrolment ratio at that age.
Source: UNESCO Institute for Statistics [web site]. Montreal, UNESCO Institute for Statistics,
2005 (http://www.uis.unesco.org/en/stats/statistics/indicators/i_pages/indspec/tecspe_sle.htm,
accessed 15 June 2005).
Health expenditure
GDP (gross domestic product) is the value of goods and services provided in a country by
residents and non-residents without regard to their allocation among domestic and foreign
claims. This corresponds to the total sum of expenditure (consumption and investment) of the
private and government agents of the economy during the reference year.
General government expenditure includes consolidated direct and indirect outlays,
including capital, of all levels of government, social security institutions, autonomous bodies
and other extrabudgetary funds.
International dollars are derived by dividing local currency units by an estimate of
their purchasing power parity (PPP) compared to US dollar, a measure that minimizes the
consequences of differences in price levels between countries.
Total health expenditure is the sum of general government expenditure on health and
private expenditure on health in a given year (in international dollars).
Source: World health statistics 2005. Indicators [online database]. Geneva, World Health
Organization, 2005 (http://www3.who.int/statistics/compendium.htm#totexponhealthasperce
ntofgdp, accessed 15 June 2005).
Exposure to household tobacco smoke
Percentage of those aged 0–4 years who live in households in which any member smokes.
Source: Rigby M, Köhler L, eds. Child health indicators of life and development (CHILD). Report
to the European Commission. Luxembourg, Directorate-General for Health and Consumer
Protection, 2002 (http://www.ggd.nl/kennisnet/uploaddb/downl_object.asp?atoom=15443&V
olgNr=1, accessed 15 June 2005).
ANNEX. DEFINITIONS
Fair or poor health
Percentage of 15-year-olds rating their health as fair or poor.
Source: Currie C et al., eds. Young people’s health in context. Health Behaviour in School-aged
Children (HBSC) study: international report from the 2001/2002 survey. Copenhagen, WHO
Regional Office for Europe, 2004 (Health Policy for Children and Adolescents, No. 4; http://
www.euro.who.int/eprise/main/who/informationsources/publications/catalogue/20040518_1,
accessed 25 May 2005).
Gini index
The Gini index measures the extent to which the distribution of income (or consumption)
among individuals or households within a country deviates from a perfectly equal distribution.
A value of 0 represents perfect equality, a value of 100 perfect inequality.
Source: World health statistics 2005. Indicators [online database]. Geneva, World Health
Organization, 2005 (http://www3.who.int/statistics/compendium.htm#totexponhealthasperce
ntofgdp, accessed 15 June 2005).
Good parental support
Percentage of 15-year-olds who find it easy to talk to their mothers.
Source: Currie C et al., eds. Young people’s health in context. Health Behaviour in School-aged
Children (HBSC) study: international report from the 2001/2002 survey. Copenhagen, WHO
Regional Office for Europe, 2004 (Health Policy for Children and Adolescents, No. 4; http://
www.euro.who.int/eprise/main/who/informationsources/publications/catalogue/20040518_1,
accessed 25 May 2005).
High life satisfaction
Percentage of 15-year-olds who place themselves above the middle of a life-satisfaction scale
(scores of 6 or more on a ten-point scale, the Cantril ladder).
Source: Currie C et al., eds. Young people’s health in context. Health Behaviour in School-aged
Children (HBSC) study: international report from the 2001/2002 survey. Copenhagen, WHO
Regional Office for Europe, 2004 (Health Policy for Children and Adolescents, No. 4; http://
www.euro.who.int/eprise/main/who/informationsources/publications/catalogue/20040518_1,
accessed 25 May 2005).
Incidence of insulin-dependent diabetes
Estimated annual number of newly diagnosed cases of childhood-onset type 1 diabetes
(requiring insulin for survival) per 100 000 people aged 0–14 years.
Source: Diabetes atlas, 2nd ed. Brussels, International Diabetes Federation, 2003.
Incidence of measles, all ages (annual average)
The incidence is the number of all new cases of measles in a year, in all age groups, that are
reported by a country to WHO, divided by the total population of the country. As the number of
cases per year fluctuates considerably, the average number of cases per 100 000 population per
year for 1998–2002 is presented.
Source: devised at the WHO Regional Office for Europe for this report.
125
126
T H E E U R O P E A N H E A LT H R E P O R T 2 0 0 5
Leukaemia survival
National estimates of five-year observed cumulative survival.
Source: Automated Childhood Cancer Information System (ACCIS) [online database]. Lyon,
International Agency for Research on Cancer, 2003 (http://www-dep.iarc.fr/accis/data.htm,
accessed 15 June 2005).
Life expectancy at birth
Average number of years that a newborn baby is expected to live if current mortality rates
continue to apply.
Source: World health statistics 2005. Indicators [online database]. Geneva, World Health
Organization, 2005 (http://www3.who.int/statistics/compendium.htm#lifeexpectancy,
accessed 15 June 2005).
Living in a single-parent family
Percentage of children aged 11–15 years who report living in a single-parent family, with the
main home as the reference.
Source: Currie C et al., eds. Young people’s health in context. Health Behaviour in School-aged
Children (HBSC) study: international report from the 2001/2002 survey. Copenhagen, WHO
Regional Office for Europe, 2004 (Health Policy for Children and Adolescents, No. 4; http://
www.euro.who.int/eprise/main/who/informationsources/publications/catalogue/20040518_1,
accessed 25 May 2005).
Low birth weight
Percentage of live-born infants weighing less than 2500 g at birth in a given time period.
Source: World health statistics 2005. Indicators [online database]. Geneva, World Health
Organization, 2005 (http://www3.who.int/statistics/compendium.htm#lowbirthweight,
accessed 15 June 2005).
Low socioeconomic status
Percentage of children aged 11–15 years reporting low family affluence according to a
composite score on the family affluence scale (FAS), based on family car ownership, bedroom
occupancy, family holidays and computer ownership.
Source: Currie C et al., eds. Young people’s health in context. Health Behaviour in School-aged
Children (HBSC) study: international report from the 2001/2002 survey. Copenhagen, WHO
Regional Office for Europe, 2004 (Health Policy for Children and Adolescents, No. 4; http://
www.euro.who.int/eprise/main/who/informationsources/publications/catalogue/20040518_1,
accessed 25 May 2005).
Maternal mortality rate
Number of maternal deaths per 100 000 live births during the same time period.
Source: World health statistics 2005. Indicators [online database]. Geneva, World Health
Organization, 2005 (http://www3.who.int/statistics/compendium.htm#maternalmortality,
accessed 15 June 2005).
ANNEX. DEFINITIONS
One-year-olds immunized against measles
Percentage of 1-year-olds who have received at least one dose of measles-containing vaccine in a
given year. For countries recommending the first dose of measles among children older than 12
months of age, the indicator is calculated as the proportion of children aged less than 24 months
receiving one dose of measles-containing vaccine.
Source: World health statistics 2005. Indicators [online database]. Geneva, World Health
Organization, 2005 (http://www3.who.int/statistics/compendium.htm#measles, accessed 15
June 2005).
One-year-olds immunized with DTP3
Percentage of 1-year-olds who have received three doses of the combined diphtheria and
tetanus toxoid and pertussis vaccine in a given year.
Source: World health statistics 2005. Indicators [online database]. Geneva, World Health
Organization, 2005 (http://www3.who.int/statistics/compendium.htm#dtp3, accessed 15 June
2005).
One-year-olds immunized with hepatitis B3
Percentage of 1-year-olds who have received three doses of hepatitis B3 vaccine in a given year.
Source: World health statistics 2005. Indicators [online database]. Geneva, World Health
Organization, 2005 (http://www3.who.int/statistics/compendium.htm#hepb, accessed 15 June
2005).
Oral health (DMFT)
Number of decayed, missing or filled teeth at age 12 (DMFT-12 index).
Source: European health for all database [online database]. Copenhagen, WHO Regional Office
for Europe, 2005 (http://www.euro.who.int/hfadb; accessed 2 May 2005).
Overweight
Percentage of 15-year-olds classified as overweight (combined total of pre-obese and obese)
using self-reported weight and height data and international cut-off points that correspond to
adult body mass index (BMI) values of 25.0–29.0 for overweight and ≥ 30.0 for obesity; BMI =
weight (kg)/height (m)2.
Source: Currie C et al., eds. Young people’s health in context. Health Behaviour in School-aged
Children (HBSC) study: international report from the 2001/2002 survey. Copenhagen, WHO
Regional Office for Europe, 2004 (Health Policy for Children and Adolescents, No. 4; http://
www.euro.who.int/eprise/main/who/informationsources/publications/catalogue/20040518_1,
accessed 25 May 2005).
Prevalence of asthma
Percentage of children aged 13–14 years reporting asthma symptoms in the previous 12
months.
127
128
T H E E U R O P E A N H E A LT H R E P O R T 2 0 0 5
Source: Tamburlini G, von Ehrenstein O, Bertollini R, eds. Children’s health and environment: a
review of evidence. Copenhagen, European Environment Agency, 2002:44–47 (Environmental
Issue Report No. 29; http://www.euro.who.int/document/e75518.pdf, accessed 25 May 2005).
Stunting in children under 5
Percentage of children aged under 5 years who have a height for age below –2 standard
deviations of the United States National Center for Health Statistics/WHO reference median.
Source: World health statistics 2005. Indicators [online database]. Geneva, World Health
Organization, 2005 (http://www3.who.int/statistics/compendium.htm#childrenstunted,
accessed 15 June 2005).
TB under DOTS
Case detection means that TB is diagnosed in a patient and is reported.
Cases detected under DOTS are the percentage of the total number of smear-positive
TB cases estimated to occur countrywide in a given year that are diagnosed (correctly or
incorrectly) and reported under DOTS to the national health authority.
Detection under DOTS implies that all components of the internationally recommended
DOTS strategy for TB control are in place where patients are detected: political commitment,
uninterrupted drug supply, use of smear microscopy in diagnosis, standardized short-course
treatment regimens, direct observation of treatment and monitoring of treatment outcomes for
100% of patients with TB.
DOTS case detection rate is the ratio of the number of notified new smear-positive cases by
DOTS programmes to the total number of new smear-positive cases estimated for that year and
country. The case detection rate and the DOTS case detection rate are identical when DOTS
coverage is 100%.
The number of cases notified is usually smaller than estimated new cases because of
incomplete coverage by health services, underdiagnosis, or deficient recording and reporting.
The calculated detection rate can exceed 100%, however, if case finding has been intense in an
area that has a backlog of chronic cases, if there has been overreporting (for example, double
counting) or overdiagnosis, or if estimates of incidence are too low. If the expected number of
cases per year is very low, the case detection rate can vary markedly from year to year, owing
to chance. Whenever this index comes close to or exceeds 100%, WHO attempts to investigate
which of these explanations is correct.
Treatment success is the percentage of a group of TB cases registered under DOTS in a
specified period that successfully completed treatment, whether with bacteriologic evidence of
success (“cured”) or without (“treatment completed”). For new smear-positive cases, there is a
target of 85% treatment success, based on the assumption of what can be reasonably achieved
assuming the baseline proportion of unfavourable outcomes (death, failure and default) to be
about 15%.
Sources: World health statistics 2005. Indicators [online database]. Geneva, World Health
Organization, 2005 (http://www3.who.int/statistics/compendium.htm#dotsdetected and
http://www3.who.int/statistics/compendium.htm#dotstreated, accessed 15 June 2005) and
Methods. Monitoring progress towards the Millennium Development Goals. In: Global
tuberculosis control: surveillance, planning, financing. WHO report 2005. Geneva, World Health
ANNEX. DEFINITIONS
Organization, 2005 (http://www.who.int/tb/publications/global_report/2005/methods/en/
index.html, accessed 15 June 2005).
Tobacco smoking
Percentage of 15-year-olds who report that they smoke every day.
Source: Currie C et al., eds. Young people’s health in context. Health Behaviour in School-aged
Children (HBSC) study: international report from the 2001/2002 survey. Copenhagen, WHO
Regional Office for Europe, 2004 (Health Policy for Children and Adolescents, No. 4; http://
www.euro.who.int/eprise/main/who/informationsources/publications/catalogue/20040518_1,
accessed 25 May 2005).
Total fertility rate
Number of children that would be born per woman, assuming no female mortality at
childbearing age and the age-specific fertility rates of a specified country and reference period.
Source: United Nations Common Database [online database]. New York, United Nations
Statistics Division, 2005 (http://first.sipri.org/www/first_un_life.html, accessed 15 June 2005).
Under-5 mortality rate
Probability of dying (per 1000 live births) before reaching the age of 5 years in a specified
period, if subject to age-specific mortality rates of that period.
Source: World health statistics 2005. Indicators [online database]. Geneva, World Health
Organization, 2005 (http://www3.who.int/statistics/compendium.htm#under5mortality,
accessed 15 June 2005).
129
The WHO Regional Office
for Europe
A synthesis of evidence and analyses from WHO and other sources, the report
identifies both noncommunicable diseases as the main cause of the burden
of disease on the Region, and communicable diseases as an additional
burden on eastern countries, caused by poverty and underfunded health
services. It shows that using well-known, comprehensive interventions
to tackle the leading risk factors – tobacco, alcohol, high blood pressure,
high cholesterol, overweight, low fruit and vegetable intake, and physical
inactivity – would largely prevent the leading conditions – ischaemic heart
disease, unipolar depressive disorders, cerebrovascular disease, alcohol-use
disorders, chronic pulmonary disease, lung cancer and road traffic injury.
This creates a compelling argument for action.
Member States
Albania
Andorra
Armenia
Austria
Azerbaijan
Belarus
Belgium
Bosnia and Herzegovina
Bulgaria
Croatia
Cyprus
Czech Republic
Denmark
Estonia
Finland
France
Georgia
Germany
Greece
Hungary
Iceland
Ireland
Israel
Italy
Kazakhstan
Kyrgyzstan
Latvia
Lithuania
Luxembourg
Malta
Monaco
Netherlands
Norway
Poland
Portugal
Republic of Moldova
Romania
Russian Federation
San Marino
Serbia and Montenegro
Slovakia
Slovenia
Spain
Sweden
Switzerland
Tajikistan
The former Yugoslav
Republic of Macedonia
Turkey
Turkmenistan
Ukraine
United Kingdom
Uzbekistan
The European health report 2005 has a special focus on children’s health,
because health in childhood determines health throughout life and into
the next generation. It reveals differences between the patterns of ill
health in children and in adults, and wide differences in the causes and
rates of illness and death in children across the Region. This shows the need
for complementary policies on adults and children and the complexity
of the task countries face in working to improve children’s health. While
recognizing that each country must chart its own course, the report identifies
poverty and socioeconomic inequality as the greatest threats to children’s
health, calls for renewed effort in protection and promotion, and provides an
evidence-based list of the characteristics of the most successful policies and
programmes. Investing in children’s health is investing in the future.
World Health Organization
Regional Office for Europe
Scherfigsvej 8, DK-2100 Copenhagen Ø, Denmark
Tel.: +45 39 17 17 17. Fax: +45 39 17 18 18.
E-mail: [email protected]
Web site: www.euro.who.int
The World Health Organization
(WHO) is a specialized agency
of the United Nations created
in 1948 with the primary
responsibility for international
health matters and public
health. The WHO Regional Office
for Europe is one of six regional
offices throughout the world,
each with its own programme
geared to the particular health
conditions of the countries it
serves.
The European health report 2005. Public health action for healthier children and populations
Governments and policy-makers in the WHO European Region know that
good health is a fundamental resource for social and economic development.
While rightly proud of the overall improvement in health in the Region, they
still face a widening gap between the western and eastern countries in the
Region and between socioeconomic groups in countries. Reducing these
inequalities is increasingly vital. The European health report 2005 shows
that it is also feasible. The report summarizes the major public health issues
facing the Region, particularly its children, and describes effective policy
responses. This helps to supply the reliable, evidence-based information
needed for sound decision-making on public health.
Was this manual useful for you? yes no
Thank you for your participation!

* Your assessment is very important for improving the work of artificial intelligence, which forms the content of this project

Download PDF

advertisement