COMVIISSION OF THE EUROPEAN COMMUNITIES 
C0M(93)559 final 
Brussels, 24 November 1993 
Commission communication on the framework 
for action in the field of public health 
COMMISSION COMMUNICATION ON THE FRAMEWORK 
FOR ACTION IN THE FIELD OF PUBLIC HEALTH 
CONTENTS 
EXECUTIVE SUMMARY 
PART A 
Background to public health policy 
I. Introduction p.3 
a) Current health challenges in the Member States of the Community p.3 
b) Scope of public health policy p. 5 
II. Health status and trends in the Member States p.6 
a) Mortality p. 6 
b) Morbidity p. 6 
III. The basis for Community action p.9 
a) Subsidiarity p.9 
b) Legal bases p.9 
c) Past consideration of health matters by Community Insitutions p. 11 
!«. 
PARTB 
The European Community approach 
IV. Selection of Activities p.15 
a) Scope of possible activity p.15 
b) The means of Community action p. 16 
c) Selection of areas of activity p. 17 
i) selection criteria p.17 
ii) major health scourges other than drugs p. 18 
iii) drug dependence p.20 
iv) rare diseases p.20 
V. Causation of diseases p.20 
VI. The nature and extent of Community involvement p.23 
a) General approach p.23 
b) Consultation and participation mechanisms p.26 
c) Support to Member States' action and promotion of coordination p.26 
d) Information, education and health promotion p.27 
e) Research p.28 
f) Training of health professionals p.29 
g) Cooperation with international organisations and third countries . . . p.30 
i) International organisations p.31 
ii) Third countries p.32 
VII. Future action in the field of public health . p.33 
Annex I OVERVIEW OF MEMBER STATES PREVENTION AND 
HEALTH PROMOTION POLICIES p. 35 
Annex II COMMUNITY POLICIES AND INSTRUMENTS OF DIRECT 
RELEVANCE TO HEALTH PROTECTION p. 40 
Annex III HEALTH PROTECTION REQUIREMENTS AS A CONSTITUENT PART 
OF OTHER COMMUNITY POLICIES p. 46 
Annex IV IDENTIFICATION OF MAJOR HEALTH SCOURGES 
IN THE EUROPEAN COMMUNITY p. 49 
Annex V STATISTICAL DATA p. 51 
It 
EXECUTIVE SUMMARY 
This communication sets out the Commission's proposals for taking forward the Community's 
work on public health to meet the objective introduced by the Treaty on European Union that 
"the Community shall contribute towards ensuring a high level of human health protection" 
(Article 129). It defines a framework for action by the Community, and describes the role of 
the Community Institutions and the Member States. It sets out a strategy for action, identifies 
the means available to the Community to accomplish its aims and establishes the procedures 
for evaluation, review and consultation. Finally, key areas of action are selected for the next 
five years. 
The Communication is divided into two parts. The first part sets out the background to public 
health policy, and the second describes the European Community approach. 
A. Background to public health policy 
Chapter I of the document provides an overview of the main health-related problems and 
challenges facing Member States today. These problems relate to : 
the ageing population of the Community, 
increasing population mobility into the Community and between Member 
States, 
changes in the environment and in the work setting, 
rising expectations about what health services can and should deliver, and 
the general socio-economic problems of the Community, notably social 
exclusion. 
As a result of these problems Member States have been facing increasing pressures on the 
provision of health services and these are likely to grow in the future. 
The scope of public health policy is then set out and how it involves activities aimed at 
individuals' immediate environment and the more general context in which they live. 
Annex I of the communication summarises the Member States' prevention and health 
promotion policies. 
Chapter II presents a description of the major trends in health status in Member States based 
on available mortality and morbidity data. The figures show that in recent decades there has 
been a substantial improvement in overall health status, with people living longer, and that 
cancer and cardiovascular diseases, and for young people accidents, are the major causes of 
death in the Community. Other conditions producing significant morbidity and mortality are 
listed. Annex V presents more detailed statistical data. 
Chapter III sets out the basis for Community action on public health. It describes the 
application of the principles of subsidiarity, transparency and proportionality to this area, 
emphasising that questions of the finance and delivery of care and treatment services are for 
each Member States to determine. 
Ac 
The legal bases for Community activities in health are outlined (the policies, programmes and 
instruments giving effect to them are set out in Annexes II and III). The provisions and 
significance of Article 129 are then set out in detail. The main elements of this Article are 
the focus on prevention of diseases, particularly the "major scourges", including drug abuse; 
the stress that health requirements must be considered in developing other Community 
policies, and the obligation on the Commission to liaise with the Member States in the 
coordination of their policies and programmes. 
The chapter finally outlines the work undertaken by the European Council, the Council, the 
European Parliament and the Economic and Social Committee in the development of Community 
public health policy. 
B. The European Community approach 
Chapter IV first sets out the scope of possible Community action in public health and the 
objectives of such Community action. It then describes the means of undertaking Community 
action in this field, including the establishment of common objectives and of networks, 
exchange of information and personnel, improvement of data systems, financial support to 
programmes and projects, production of an annual Community health report, and assistance 
to cost reduction efforts. 
Principles for identifying diseases or health threats for Community action are given. The 
selection involves consideration of both diseases' effects on the health status of the Community 
population and whether preventive action can appropriately be taken at Community level 
(Annex IV lists important health scourges and their impact. 
On this basis cancer, cardio-vascular diseases, accidents, AIDS and communicable diseases, 
drug dependence and rare diseases are deemed to be appropriate targets for action. 
Chapter V on causation of diseases makes the point that for effective disease prevention, it 
is vital that their underlying causes are addressed by a mixture of measures. Important causal 
factors, such as smoking and alcohol, are set out together with data on their trends in the 
Community. 
Chapter VI on the nature and extent of Community involv^nent explains the broad 
mechanisms that the Commission will use in taking forward the oojecjtives of policy. It will 
give priority to large-scale, wide impact projects and will keep a "health watch" on other 
Community programmes and policies as they develop. 
The kinds of general mechanisms to be used are described in detail : 
Consultation and participation. Appropriate mechanisms will be set up to give 
advice to the Commission on formulating and implementing activities. 
Promotion of programme and policy coordination. Comparisons and 
evaluations of prevention policies and cost-effectiveness analyses will be made 
and networks to monitor diseases set up. 
Cooperation with international organisations and third countries. Existing 
/it-
cooperation with relevant international bodies such as WHO will be increased 
e.g. by commissioning specific work from them, conducting joint programmes 
or supporting their programmes. With regard to third countries, existing 
assistance schemes will be stepped up and consideration will be given to 
undertaking further cooperation with particular countries notably in Central and 
Eastern Europe. 
Information, education and health promotion. A coordinated programme of 
health education and promotion measures will be developed aiming both at 
causal factors and specific diseases. This will take forward the work already 
being carried out in certain areas e.g. AIDS and cancer. 
Research. Steps will be taken to strengthen links with the Community research 
programmes, as defined in the Fourth Research and Development framework 
Programme, to ensure that the research needs of public health are met, to 
establish a strategy for public health research and to ensure that the results are 
properly disseminated. 
Training of health professionals. To increase the effectiveness of health 
professionals' role in public health, existing courses will be evaluated, 
collaboration on new ones promoted, and exchanges of experiences and 
information on teaching and training will be fostered. 
Chapter VII on future action in the field of public health sets out, on the basis of the 
arguments in the preceding chapters, the priority areas for Community action in public health. 
The areas proposed cover "horizontal" activities and disease - specific ones. They are : 
Health promotion, education, information and training, 
Health data and indicators, and monitoring and surveillance of diseases, 
Cancer, 
Drugs, 
AIDS and other communicable diseases, 
Accidents and injuries, 
Pollution - related diseases, 
Rare diseases, 
Other health threats (if circumstances require). 
This communication is only a first step towards a continuing effort of developing policies, 
programmes and individual actions designed to give full effect to Article 129, and to other 
articles in the Treaties of relevance to health protection. It would be followed by a series of 
programmes on each of the identified topics above. The Commission hopes that it will stimulate 
debate, help concentrate attention on health prevention and promotion, as has been the case in 
Member States on health care and treatment, and build lasting partnerships and networks in the 
common endeavour to bring about a high level of health protection in the European Community. 
1 
PART A 
BACKGROUND TO PUBLIC HEALTH POLICY 
I. INTRODUCTION 
1. This Communication sets out the Commission's proposals for a framework for action in the field 
of public health in the light of the ratification of the Treaty on European Union, which introduced 
Articles 3(0) and 129, with explicit provisions on public health, in the Treaty establishing the 
European Community, 
2. In essence the Communication does four things: first it sets out the major issues in relation to 
health which confront the Community. Second, it explains how priorities for Community action can 
be established. Third, it describes the kinds of actions that are possible and how they fit together 
with what has been done so far on public health by the Community and by Member States and also 
with other Community programmes. Finally a number of specific programmes of actions are 
proposed. 
3. The proposed framework set out in this Communication is intended to build upon the important 
contributions made by the Council, the European Parliament, and the Economic and Social 
Committee in this area, as well as the work of the Commission. It takes full account of all the 
principles for Community action laid down in the Treaty on European Union and in the other 
Treaties. 
a) Current health challenges in the Member States of the European Community 
4. The wide cultural, social and economic diversity of the European Community means that the 
different Member States are confronted with a variety of health protection problems. But there are 
also several important common issues which bear on health matters across the Community as a 
whole. Such issues include the following: 
- ageing population. The proportion of people of 60 and over in the Community is rising. From only 
17.5% in 1980 one scenario depicts that it will reach 24% by 2010. This increase will mean that 
progressively there will be both larger numbers of elderly people who are disproportionate users of 
health services, and the burden of paying for them will fall on a relatively smaller working 
population Thus the need for medical care threatens to outstrip society's ability or willingness to 
provide it. In addition, whether countries spend a larger or smaller amount on medical care, studies 
show that the impact of treatment on the population's mortality rates is outweighed by the power 
of the factors affecting the incidence of diseases such as cancers and cardiovascular diseases, and 
that the decline in old-age mortality is accompanied by a rise in the untreatable disabilities now 
common among the old. Studies also suggest that recently the average number of years that people 
spend disabled has grown faster than the number of years they spend healthy. 
- increasing population mobility. Migration into the European Community, the coming into effect 
of the single market and the general increase of travel and tourism are producing an ever-larger 
intermingling of populations. The health implications of this trend include the propensity for 
spreading communicable diseases more rapidly, the potential for increased drug abuse and the 
potential difficulties of providing for the specific needs of migrant communities; 
- diseases asising from environmental changes and workplace environments. A number of health 
problems are being produced by changes in the environment resulting from economic and 
(2) 
technological developments. The increased levels of respiratory illnesses and certain forms of cancer 
Can for example be linked to such changes. Moreover the introduction of new working methods and 
modern machinery and computers into the workplace environment can also lead to physical and 
psychological health problems. Conditions related to stress and musculo-skeletal problems are also 
increasing significantly. 
- rising expectations concerning health. The factors above which are leading to growing demands 
for health services are accompanied by people's concomitant rising expectations of what the health 
services can provide. The continuing development of powerful technologies for diagnosis and 
treatment has fostered this expectation of more and better provision and the desire of everyone, and 
especially the disavantaged groups and poorer regions, to have access to it. The economic costs of 
this are increased by the fact that many new procedures rely on sophisticated and more costly drugs 
and equipment. 
- socio-economic 
of unemployment are 
limits both the amount 
Moreover, unemployment 
lead to health problems probleihs, in particular social exclusion. Slow economic growth and high levels 
leading Member States to apply tight constraints on public spending. This 
aivailable for health services and what can be spent on social assistance. 
, inequalities, discrimination, poverty and social exclusion can themselves 
5. As a result of the health-related issues outlined above which confront the Member States, their 
health spending has risen rapidly in the last two decades. As shown in Figure 1 (Annex V), during 
the 1970's and 1980's, health expenditure increased significantly in relation to Gross Domestic 
Product (GDP), partly reflecting the slowdown in the rate of the economic growth. In the latter part 
of the 1980's, however, the figures for certain Member States stabilised and even declined as growth 
picked up. Nevertheless, costs containment remains a topic of major concern in the 1990's especially 
in the context of the present recession and the budget constraints on public expenditure growth. 
Member States have been acting vigorously to contain costs, and cost containment has been achieved 
only by taking steps both to limit provision, as for example by controls on drug prescribing and 
medical recruitment, and to hold back demand, including the imposition of charges for drugs and 
tests. 
6. The underlying pressures on services have not disappeared and are likely to intensify, despite 
the fact that there is little correlation between the main health indicators and health spending. 
Furthermore it has been established that lower service spending has disproportionate effects on the 
poor, sick and old. Hence there is a need for well-balanced responses to the inevitable pressures to 
adjust health spending, such as public health initiatives (eg, smoking cessation, diet and exercise, 
air pollution controls, etc.) better structuring and financing of health systems to minimize costs, 
cutting out ineffective treatments and evaluating medical equipment and medicines in cost/benefit 
terms. 
7. The difficulties invol ved in taking the right decisions in health protection under severe economic 
constraints prompted the Council to agree, inter alia, the Resolution concerning fundamental health 
policy choices of 11 November 1991 (OJN* C304 of 23.11.1991). This Resolution, and indeed the 
Treaty on European Union, makes it plain that Member States accept an obligation to ensure that 
their citizens enjoy a high standard of health. This ethical and legal obligation to protect the health 
of the public is reinforced by the economic benefits, for specific age groups and activity sectors (e.g. 
in perinatal care), of taking health promotion, protection and preventive measures. 
8. By taking effective 
as can disablement and 
for work; health can 
controlled. In short, the 
costs of ill health 
economic advantages Îïtion, premature deaths among the productive population can be prevented, 
hronic illnesses with the consequent effects of absenteeism and unfitness 
improved and demands upon health care and treatment services can be 
Community's productive capacity can be maximised and simultaneously the 
reduced. Finally, and most important, safeguarding health, as well as producing 
can also improve the quality of life, which will have inestimable benefits both 
for the individual as well as for society as a whole. 
b) Scope of public health policy 
9. Against this backdrop the scope of public health activities can be delineated by a consideration 
of the risks to the health of the members of a community, and of the steps needed to protect 
individuals within that community from those risks and to increase the likelihood of their living 
a full and healthy life. Apart from risks to health related to individual genetic, physical and mental 
make-up, risks to health derive both from one's chosen life style and one's immediate surroundings, 
in particular at home and work, and from the local environment - the combination of social, 
economic and cultural conditions that provide the general context for people's lives. Thus the steps 
required to protect individuals! health must address both of these "environments". 
10. While the actions and programmes of the public authorities have dominated the development 
of public health strategies, in the last three decades public health interest has focused increasingly 
on the responsibility of the individual for his/her own health and the modifications he can make to 
his/her own behaviour to prevent the onset of disease. Such considerations have been applied to diet, 
the taking of sufficient exercise, the avoidance of dangerous and toxic substances, including drug 
abuse, and the prevention of accidents. 
11. International control of disease first appeared in the form of national quarantine schemes in 
Europe and the Middle East to contain the spread of epidemic disease from one country to another. 
These efforts first demonstrated the need for international cooperation for health protection. A 
permanent international health organization was established in Paris in 1907 to receive notification 
of serious communicable diseases from participating nations, to transmit this information to the 
Member Nations, and to study and develop sanitary conventions and quarantine regulations on 
shipping and train travel. This organization was ultimately absorbed by the World Health 
Organization (WHO) in 1948. 
12. The WHO undertakes both short-and long-term projects to control or eradicate diseases on a 
world scale and maintains close relationships with other United Nations specialized agencies, also 
dealing with health issues, particularly the United Nations International Children's Fund (UNICEF), 
the Food and Agricultural Organization (FAO), and the International Labour Organization (ILO). 
13. The Community has, from the outset, made health and well being one of its primary goals; 
health concerns underlie the economic objectives of the EEC Treaty, the safety provisions of the 
ECSC Treaty and the protection requirements of the Euratom Treaty. It is for these reasons that the 
Treaty on European Union (TEU), makes health protection one of the centrepieces of the quest for 
ever closer union of the peoples of the Community, and enjoins upon the Community and the 
Member States' Governments to contribute to the attainment of a high level of health protection. 
IL HEALTH STATUS AND TRENDS IN THE MEMBER STATES 
a) Mortality 
14. The last decades have been characterised by two major trends in the health status of the 
population of the European Community. First, on the basis of mortality indicators, there is clear 
evidence of a considerable and continuing improvement in overall health status. People are living 
longer and fewer infants are dying in all Member States. Between 1960 and 1989 life expectancy 
for men across the 12 Member States rose from 67.3 to 72.8 years, and for women, from 72.7 to 
79.2 years. Moreover, while the Member States with the best records have continued to improve, 
those with lower rates have been catching up. The range between the Member States has thus 
narrowed, halving between 1970 and 1988. Even more striking, the lowest life expectancy figure 
in 1988 for the whole population of a Member State (74.3 years) was better than the best in 1970 
(73.8 years). 
15. A similar but even more dramatic picture emerges from the figures on infant mortality in the 
Community. This figure has dropped by a factor of more than four from 34.8 per 1000 in 1960 to 
8.2 in 1989. As with life expectancy there has been a substantial narrowing of the range between 
best and worst, and again the worst Member State in 1989 (12.18 per 1000) was better than the best 
in 1970 (12.75 per 1000). 
16. The second trend is that of a significant shift in the causes of death, with communicable diseases 
(AIDS excluded) decreasing considerably in importance thanks to better hygiene and living 
conditions, preventive measures, such as vaccination programmes, and the availability of effective 
treatments. They have been replaced to a large extent by other diseases, notably cancer and cardio­
vascular diseases. Whereas just over one half of the 2.9 million deaths in the Community in 1960 
resulted from these latter diseases, by 1990 the proportion had risen to two thirds. Of the 3.3 million 
deaths, 1.4 million were from cardio-vascular diseases and 0.8 million from cancer. These diseases 
are not only the primary cause of death among the over - 65s, but also among the population 
between 35-65 years of age, thus contributing significantly to premature death, as do accidents for 
the 5 to 34 - year old group. The patterns of mortality are continuing to change, however. There is 
for example evidence of a recent decline in mortality from cardio-vascular diseases and an increase 
in deaths from previously rare diseases such as Alzheimer's disease. Such developments reflect 
demographic changes, advances in therapy and the launch of large-scale preventive programmes. 
b) Morbidity 
17. Mortality rates provide only an incomplete picture of the overall health status of a population. 
For a full picture, information is also necessary on morbidity i.e. the numbers of people with a 
particular illness or other medical condition. Such information reveals not only which are the most 
prevalent illnesses in the population, but it is also an indication of the demands made upon the 
health care system. Unfortunately, although individual Member States have morbidity data, owing 
to substantial differences in collection methods and definitions, few comparable morbidity data exist 
at present for the Community as a whole. 
18. One notable exception is for traffic accidents where information is available both for deaths and 
for injuries in the Community. Overall these figures show a decline in the death rate in the 
Community from traffic accidents in the period 1970 - 1990 and a smaller and patchier decline in 
the rate of injury. Younger age-groups are predominantly involved. In the light of the discussions 
on the White Paper on the development of transport policy, the Commission has published a 
Communication on an action programme on road safety (COM(93) 246 of 9 June 1993) and a 
proposal for a Council decision on the establishment of a database on road accidents (COM(593) 
of 23 July 1993). Some information is also available on cardio-vascular disease as seven Member 
States are participating in the MONICA study run by WHO which collects mortality and morbidity 
data in this field. The data indicate that just as cardiovascular diseases are the major cause of 
mortality in the Community, so they are a cause of serious morbidity in the middle and old-aged 
population. 
19. Comprehensive comparative data do not exist for other conditions. However, national statistics 
do provide pointers to the relative importance of the various diseases in terms of morbidity. Table 
1 gives figures for the principal diseases in Denmark and France according to their percentage of 
total hospital admissions and bed-days. These show that despite some differences, the overall 
patterns in both countries are not dissimilar, with the same kinds of diseases being important in both 
countries. 
Table 1 
RELATIVE IMPORTANCE OF DIFFERENT DISEASES MEASURED BY HOSPITAL ADMISSIONS AND 
BED-DAYS + 
FRANCE 1985-1987 DENMARK 1990 
Admissions Bed-Days Admissions Bed-Days 
Injuries 13.2 11.7 7.7 13.9 
Digestive 
system 
disorders 12.7 12.0 7.1 6.7 
Cardio­
vascular 11.6 15.5 24.9 21.9 
Cancer 10.2 12.5 11.7 8.9 * 
Respiratory 
conditions 6.9 5.8 10.4 8.8 
Musculo­
skeletal 
conditions 6.3 7.0 14.8 15.5 
Other diseases 39.1 35.5 23.4 24.3 
+ Indicative data, provided by the Ministries of Health, not directly comparable due to differences in definitions, 
classification and periods of reference. 
* Danish figures for cancer include lung and breast cancers only. 
20. The data that exist confirm that cardio-vascular diseases are the most important contributors to 
Community morbidity, just as they are to mortality, but they indicate that cancer is of less 
importance in morbidity than in mortality and that there are several non-fatal diseases which are of 
considerable significance in morbidity, notably respiratory and musculo-skeletal diseases. Taken 
together the mortality figures and the information available on morbidity make it possible to draw 
up a list of those diseases which produce high mortality and/or high morbidity. Table 2 gives those 
diseases which pose particularly serious health problems for the Community as a whole : 
Table 2 
DISEASES PRODUCING HIGH MORTALITY AND/OR MORBIDITY 
Accidents 
Cardio-vascular diseases 
Cancer 
Mental illness, including suicide 
Musculoskeletal conditions 
Respiratory diseases, including asthma 
21. In addition, some communicable diseases, which were in the past a major cause of mortality, 
are now once more on the increase. This is due in particular to the advent of AIDS and to the 
resurgence of certain important communicable diseases such as tuberculosis which had been thought 
no longer to represent a serious problem. They all have the potential to pose serious problems if no 
action is taken. Finally, the list must include drug dependence because of the substantial social and 
health problems to which it is linked, and the ever increasing numbers of individuals involved in 
drug abuse. 
22. Together then these diseases account for most of the deaths, most of the illness and most of the 
demand for health services in the Member States of the Community. But it must be emphasised that 
the figures presented above relate only to general trends. It is certainly the case that in some ways 
the differences and the gaps between best and worst Community States are narrowing. However, 
comparing national figures can give a rather distorted picture, one reason for this being the different 
sizes of the Member States. Moreover, national figures themselves tend to disguise significant 
differences between the regions within each Member State. 
23. In the case, for example, of the mortality rate from lung and bronchial cancer, in 1988 the 
overall EC mortality rate was 48.8 per 100,000. The UK has the highest rate (70.5) and Portugal 
had the lowest rate(20.6). But within the UK the rate varied nearly twofold between the north of 
England (92.4) and Northern Ireland (49.2). On its national rate (51.1) Italy came closest to the 
Community average, but that masks the fact that the rate in northern Italy was three times as high 
as that in the South. Similar large variations within States can be identified for other major diseases. 
Such variations reflect cultural, social and economic differences between regions and also the 
significant impact that environmental factors such as air pollution can have on health. 
24. Similarly, studies have shown significant variations of morbidity and mortality between different 
socio-economic groups within Member States. In 1987, for example, the perinatal and infant 
mortality rates in England were more than 50% higher for people with unskilled occupations than 
for professional groups, and in Denmark unemployed and unskilled men in poor accommodation had 
an 'excess mortality rate' of 6.2% compared with the best ranked group. It is important, therefore, 
that full account is taken of the variations not only between but also within Member States as well 
as the general patterns for the whole Community when looking at the overall status and trends in 
the Community. 
25. Moreover, in considering specific diseases as possible targets for Community action information 
about their mortality and morbidity is not by itself sufficient. It is also necessary to look at the key 
factors associated with their causation, at the more general social and economic context which bears 
on health protection and policy choices and at the efforts already undertaken by Member States to 
respond to these health challenges. An overview of the policies and measures taken by the Member 
8 
States to prevent disease and promote health, against the aforementioned background, is given in 
Annex I. 
Ill THE BASIS FOR COMMUNITY ACTION 
a) Subsidiarity 
26. The manner in which these activities by the Community and the Member States have to be 
conducted is governed by the principle of subsidiarity. Subsidiarity, the attributes of which are laid 
down in Article 3b of the Treaty establishing the European Community, implies that in matters not 
under its exclusive competence, the Community intervenes when action, by reason of its scale or 
effects, may better be carried out at Community level. Moreover, irrespective of whether a matter 
comes under its exclusive competence or not, action on it by the Community must be proportional 
to the objectives to be achieved. 
27. The following considerations apply in particular to the field of public health: 
a. In coordinating policy, the Community's role is to forge constructive relationships at all levels, 
assist in closing identified gaps, formulate and improve strategies for effective implementation 
of policies and measures, and ensure that transfers and flows of knowledge, expertise and 
materials occur to the mutual advantage of the parties concerned. 
b. In accordance with the principle of proportionality, the Community intends to focus on the 
implementation of larger rather than smaller projects, which for the most part will involve more 
than one Member State. This will maximise impact and avoid becoming involved with narrow 
issues and concerns which may be perceived as an interference with matters already dealt with 
by the authorities of the Member States, or as heavy-handedness in resorting to means out of 
proportion to the objective being pursued. 
c. Diversity in and among the Member States in diet, culture, weather conditions, land use, and 
the type and concentration of economic activity, is such that, in general, no detailed prescription 
will be handed down from the Community, even regarding problems which are identical or 
similar from Member State to Member State, region to region, locality to locality. In matters 
of health, it is up to the individual and the family to consider alternatives and take decisions on 
matters that directly affect them ; and up to society, through the democratic process, to create 
an environment conducive to the best decision being made by the individual, and to the right 
collective decisions being made in all matters where the individual cannot, alone, determine or 
bring about the desired health outcome. 
d. The Member States in partnership with their health professionals and individuals involved, are 
concerned with the financing and delivery of care and treatment. However, the Commission may 
assist the Member States in improving their collaboration on health care matters, as for example 
on fundamental health choices1, and may provide assistance to them in actions designed to 
improve the quality of health care and treatment. 
b. Legal bases 
28. Prior to the Treaty on European Union, there was no specific legal basis or competence vested 
in the Community in the field of public health. That is not to say that the Treaties did not contain 
provisions of direct relevance to the protection of health and welfare. Thus, health and safety at 
work was given from the outset a prominent place in the EEC Treaty (Articles 117, 118 and Article 
'see paragraph 7 on page 4 
,118A of the Single European Act) and in the ECSC Treaty, whereas the health protection provisions 
for both workers and members of the public contained in the Euratom Treaty (Articles 30-39) soon 
became the cornerstone for regulatory action in this field in all Member States. 
29. Other provisions in the EEC Treaty also directly or indirectly concern health: Article 2 sets out 
the duty of the Community to raise the standard of living; Article 36 allows restrictions on imports, 
and goods in transit, in order to protect the health and life of humans; Article 43 deals with 
agricultural policy which can have an impact on human health; Article 48 ensures freedom of 
movement for persons, including patients and health workers; Articles 52 to 58 are of relevance for 
the right of establishment, and in Article 59, the free movement of services, including health 
services, is guaranteed. Article 100A has a major impact on health since all proposals for directives 
establishing the Internal Market for products (e.g. blood products), services, capital and persons must 
have by virtue of this Article, a high-level of health protection as a basis; Articles 130f to 130q 
cover research including health research. In addition, the protection of human health as the ultimate 
goal of environmental protection measures is enshrined in Articles 13 Or and 130s of the EEC Treaty 
as amended by the Single European Act. Finally, Article 155 serves, inter alia, to issue 
recommendations also in matters related to health protection, and has been used in the past for 
issuing recommendations on a European list of occupational diseases, and Article 235 for proposals 
for decisions and regulations for various health related issues, such as information to the general 
public and training of members of the health professions in the framework of the "Europe against 
Cancer" programme, the setting up of a Health and Safety at Work Agency, and the creation of the 
European Monitoring Centre for Drugs and Drug Addiction (EMCDDA). 
30. The policies, programmes and instruments (see Annexes II and III) to give effect to these 
Articles played a determinant role in transforming the health scene of the Community and in raising 
the quality of life of its citizens. The Treaty on European Union, not only maintained these 
provisions but also reinforced them. Consumer protection has been given a clear mandate to protect 
the health and safety of consumers in Article 129A. Article 130 on the environment requires the 
Community to contribute to the pursuit of the objective of protecting human health. In addition, in 
Article 126, the Commumty has been given the duty to contribute to the development of quality 
education, which plays an important role in health protection and promotion. Moreover under Article 
K.9 of the Treaty on European Union, the Council, acting unanimously on the initiative of the 
Commission or a Member State, may decide to undertake action aimed at combating drug addiction. 
31. Above all, public health has, by reason of Articles 3(0) and 129, been accorded its own explicit 
provision, The Commumty has been given responsibility to contribute to the attainment of a high 
level of health protection with due regard to the principles established by the European Council in 
Edinburgh (subsidiarity, openness, transparency and proportionality) , and vested with powers to 
discharge this responsibility in a manner that ensures respect and support for Member States' 
policies and activities, prevents unwarranted intrusion and interference, and leaves room for 
adjustment and choice of the means for their implementation. In doing this, the experience gained 
hitherto in public health actions carried out by the Community serves both as guiding light and as 
a base on which to build. In particular, the "Europe against cancer" programme, launched in 1986 
by the European Council, has demonstrated the value of identifying common objectives and goals. 
It has paved the way for the adoption at Council of other programmes and initiatives dealing with 
AIDS, drug demand, alcohol abuse, and health education in schools, and has shown what can be 
achieved by partnership, cooperation, and use of instruments in other Community policies. In 
implementing the "Europe against cancer" and "Europe against AIDS" programmes, the Commission 
adopted a method which predated the principle of subsidiarity and involved a systematic attempt to 
generate Community added value, by promoting cooperation between the Member States in the 
field of studies and research, and the spread throughout the Community of the most successful 
national practices, in particular by bringing together the responsible partners in the Member States. 
10 
The achievements of these programmes and the need for their continuation were underlined during 
the recent evaluation of their effectiveness by the Council. 
32. In initiating action under Article 129, the Community has to address itself to preventing disease. 
Prevention in all its facets thus becomes the focus of Community action, whether primary, to ensure 
good health and to minimise exposure to risk factors implicated in the causation of diseases; 
secondary, to avert the onset of diseases in those so exposed, for example by screening, vaccination, 
and preventive medication/prophylaxis; or tertiary, to avert the progression or recurrence of disease. 
Prevention can be distinguished from treatment as the latter may be described as an intervention to 
correct congenital defects, or to restore an individual to a previous (better) level of health status. 
Treatment, as opposed to prevention, is therefore a matter for Member States' cooperation, and not 
an area in which the Commission can or should take initiatives on behalf of the Community. 
33. Preventive activity by the Community must of necessity address itself to the question of major 
scourges. Major scourges or health threats may be determined in relation to a host of factors, both 
objective (health data and indicators) and subjective (perception, ethical, cultural and political 
questions).Consideration of these issues is to be found in chapter IV. However one point must be 
stressed here: Article 129 specifically requires public health action on the scourge of drugs. 
34. Article 129 implicitly recognises the dichotomy between action addressed on the one hand to 
the individual to enhance his/her potential for health gain, healthy lifestyle, and non-risk or low-risk 
behaviour, such as health information and education, and, on the other hand to societal action, 
involving research into the causes and transmission of disease. This research may be fundamental, 
and also behavioural, social, and environmental, and could concern the immediate, local, and even 
remote environment, over which the individual has little, if any, control. 
35. Of primary importance is the provision of Article 129 that health protection requirements shall 
form a constituent part of the Community's other policies. In the future, elaboration of policies and 
measures with an impact on health must from the outset take account of, and be coherent with, 
public health policy. This means that other policies, despite their having different legal bases, will 
also serve the objectives of health protection. 
36. Central to the Commission's role in the implementation of Article 129 is the obligation to liaise 
with the Member States in the coordination of their policies and programmes concerning prevention, 
including drug prevention, investigation and analysis of causes and modes of transmission of health 
scourges, health information and health education. The Commission will, in close collaboration with 
the Member States, take appropriate initiatives to promote such coordination, particularly in areas 
in which the Member States have already demonstrated a need to cooperate, notably disease 
surveillance and control, health data and indicators, health information and health education, and in 
the fight against the major scourges of drugs, cancer and AIDS. 
c) Past Consideration of health matters by the Community Institutions 
i) European Council 
37. In 1986, the representatives of the Government of the Member States, meeting within 
the Council, adopted a resolution on a programme of action of the European Communities 
against cancer (86/C184/05) 2 which set the objectives of this programme and listed the 
priority actions to be considered. It also agreed on declaring 1989 as a year of information 
OJC184 of 23.7.1986 
11 
(3) 
on cancer. Moreover it called upon the Member States to draw from their experience in the 
treatment and rehabilitation of drug addicts in order to collaborate in informing teachers, 
parents, and young people about the risks related to drug addiction and in preparing a report 
and recommendations on measures that can be taken at Community level. This serious 
preoccupation with drugs was reflected in the declarations of subsequent meetings of the 
European Council, notably in London in 1986, in Dublin and Rome in 1990, in 
Luxembourg and Maastricht in 1991, and in Lisbon in 1992. The London meeting in 1986 
also stressed the importance of coordinating national campaigns against AIDS with a view 
to raising awareness and better informing the public on this disease. These resolutions and 
declarations by the European Council paved the way for Community action against the 
scourges of cancer, drugs, and AIDS. 
ii.) Council 
38. Council and Ministers of Health's interest and debate concerning public health issues 
began in 1977 and started to grow in the early 1980s. Efforts at setting an agenda in this 
field at the Community level began to revive in 1982 when the European Parliament asked 
for a clarification of what exactly had been done in the public health field since 1978, the 
year in which a second research and development programme was adopted by the Council 
in the sector of medical and public health research. The Commission's Communication on 
Community-level cooperation on health-related problems finally initiated activities in 1984. 
39. The informal meeting of Health Ministers in November 1984 discussed the increase 
of health spending, the combating of drug and tobacco addiction and health education for 
the young. The next (formal) meeting of the Health Council was held in May 1986. 
Resolutions and decisions were adopted on the action programme to fight cancer, on the 
introduction of a European emergency health card, on measures to fight against AIDS and 
on ways of decreasing the consumption of tobacco and alcohol. This and subsequent 
meetings of the Health Ministers, in which various health issues were discussed and 
important initiatives launched, raised hopes for a Community-wide health policy. 
12 
40. The signing of the Treaty on European Union on 7 February 1992 gave rise to 
heightened expectations concerning the potential for improving health protection in a 
Community where cooperation and coordination of policies and programmes, for long the 
dream of a few, could become a reality. This culminated during the second half of 1992 in 
the examination by the Health Council of fundamental questions concerning the future 
course of Community action in the field of public health. Discussion took place on the need 
for breaking with the past and looking forward to greater continuity, coherence, and 
prioritization in public health work, and to constructing an appropriate framework 
comprising the successful Community programmes on cancer and AIDS and actions in 
specific areas, such as drugs and health education in schools. In this, the Council was 
assisted by a Commission staff working paper, entitled "Public Health", which reviewed and 
took stock of the achievements of Community efforts so far, and acknowledged the need for 
a coherent approach based on prevention, health promotion, health protection through other 
Community policies, coordination between Member States, and cooperation with third 
countries and international organizations. 
41. On 27 May 1993 the Council and the Ministers for Health meeting within the Council 
adopted an important resolution on future action in the field of public health which dealt 
with all the main aspects of the public health framework in which the Community will be 
working in the future. The resolution re-affirmed the need for close cooperation and for 
consideration of the weight to be given to health requirements in other policies; and set out 
a number of guidelines concerning the fundamental objectives of action, namely adding life 
to years and years to life, the need for multi-annual planning to ensure coherence and 
continuity, the criteria for selecting areas of activity with reference to amenability to 
preventive action, and complementarity with other policies with a health component, the 
methods of cooperation and consultation, and, finally, the relations with third countries and 
international organisations. These guidelines have been studied carefully by the Commission 
and taken into account in this communication. 
iii) European Parliament 
42. The European Parliament has been in favour of a Community health policy since the 
early 1980s and has put forward several resolutions in the field of health, notably: 
health policy in the European Community (OJ. C128, 16.5.1983, p.86) 
European charter of rights of hospital patients (OJ. C46, 20.02.1984) 
Community programme of research into AIDS (OJ. C46, 20.02.1984) 
children in hospital (OJ. C148, 16.06.1986, p.37) 
women in childbirth (OJ. C235, 12.09.1988, p. 183) 
43. Members of the European Parliament have always shown a keen interest in health 
matters, as is evident from the very large number of Parliamentary questions raised on the 
subject. Its various committees, in particular the Committee on Environment, Public Health, 
and Consumer Protection, the special Committee on drugs, and the Committee on Youth, 
Culture, Education, the Media and Sport, have prepared several reports on health-related 
subjects, including reports on AIDS, health education and drug abuse, bioethics, organ 
transplantation, and blood self-sufficiency. 
13 
44. A recent report of the Committee on Environment, Public Health and Consumer 
Protection, concerning public health policy after Maastricht (1993 - PE205.804), was 
prepared following a public hearing on 3rd June 1993. The report lays particular stress on 
Article 129's call for coordination of Member States' policies and programmes and on 
integration of health requirements into other policy areas, and provides a comprehensive 
overview of current public health issues, including demography and health needs, 
comparable/compatible health data and indicators, health care costs, and research and health 
policy. The Committee made several proposals for Community action, including calls to 
the Commission to provide for widescale consultation procedures; establish an 
epidemiological investigation service; collect, analyze and disseminate data on notifiable 
diseases; encourage exchange schemes for health professionals; develop the exchange of 
information between national health systems; report on the health status of the Community; 
investigate the feasibility of encouraging greater use of generic pharmaceuticals and 
coordinate the use of all pharmaceuticals; indicate the minimum levels of health care; 
develop and execute activities on health promotion and education, including vaccinations 
and screening; and intensify its activities against cancer and AIDS, and with regard to the 
problems of the elderly. The report and a pertinent resolution will give an added impetus 
to the on-going efforts to endow the Community with a much needed public health 
dimension. 
45. Reference should also be made to the important work carried out by the European 
Parliament's "Inter-group on Health", and to its STOA group (Scientific and Technological 
Options Assessment). 
iv) Economic and Social Committee 
46. During the past ten years, the Economic and Social Committee has regularly given its 
opinions on health matters such as : occupational medicine; dangerous substances and 
preparations; the Community system of information on accidents involving consumer 
products; occupational cancer; an action programme on toxicology for health protection; 
prevention of asbestos pollution; cancer prevention action programme; and the transparency 
of medicinal product prices. More recently, the Committee approved Community initiatives 
in the social field, such as : The European Year of Older People; the Europe against Cancer 
programme and the Europe against AIDS programme, and the creation of the EMCDDA. 
* * * * * 
47. It is against a background of an expression of the will of the Community institutions, and also 
of the desires of numerous health professionals, medical and patient associations, interest groups and 
ordinary people in the Community, that the Commission, having given thorough consideration to 
the timeliness and feasibility of action on the one hand, and the available means, on the other, seeks 
with this communication to establish a coherent and comprehensive framework for Community 
public health action which will give expression to the new provisions in the Treaties. 
14 
PARTB 
THE EUROPEAN COMMUNITY APPROACH 
IV. SELECTION OF ACTIVITIES 
a) Scope of possible activity 
48. The Council and the Member States have identified a large number of areas for possible action, 
at Community level, which demonstrates the range and diversity of expectations, and underlines the 
need for the establishment of priorities in order to match resources to demands : 
- the continuation of existing Community programmes on cancer and AIDS 
- cardio-vascular diseases 
- communicable diseases 
- mental diseases 
- hereditary diseases 
- asthma and allergies 
- migration and health 
- health and environment 
- prevention of accidents and violence 
- prevention of drug abuse 
- improved data and their comparability 
- nutrition 
- tobacco 
- alcohol 
- exchanges of information on Member States' policies 
- pilot projects in prevention and early diagnosis 
- establishment of centres of excellence 
- exchange visits for health personnal 
- public health research 
- cost containment 
- fundamental health choices 
- self-sufficiency of blood 
- toxicology 
- health and young persons 
- use of pharmaceutical products 
- renal dialysis 
- emergency health card 
49. Chapter II identified on the basis of information on mortality and morbidity those groups of 
diseases and conditions which currently or potentially pose the most serious threats to the 
Community. This Chapter looks at these diseases separately in order to ascertain their suitability 
for Community action. In order to do so it is necessary to establish broad objectives for Community 
action and operational criteria based on those objectives for selecting diseases. 
15 
50. There are essentially four interlinked objectives for Community action : 
i) to prevent premature death which particularly affects the young and working population; 
ii) to increase life expectancy without disability or sickness; 
iii) to promote the quality of life by improving general health status and the avoidance of chronic 
and disabling conditions; 
iv) to promote the general well being of the population particularly by minimising the economic and 
social consequences of ill health. 
51. To attain these objectives and maximize the impact of its action, the Commumty needs to 
identify those diseases to be tackled as a matter of priority. Such identification starts with the 
examination of data which help to establish which are the major health threats, including data on 
mortality, morbidity, harm potential in the absence of intervention, amenability to preventative 
measures, perception by the public, and costs, both social and economic. On the basis of the 
Community criteria of subsidiarity and added value those major health threats for which it can be 
demonstrated that action by the Community is cost-effective, readily available and appropriate, 
can then be selected for Community action. Moreover, other diseases, which cannot be considered 
major, can also be selected for Community action provided that it can be shown that the fight 
against them would benefit from the involvement of the Commumty. 
52. Action and measures by the Community, must be relevant, transparent, and explained in such 
a way that they can be understood by the Community citizens; they should be addressed, 
nevertheless, only to decision-takers and practitioners in several Member States. Otherwise, the risk 
is that the more visible the action of the Community becomes, the greater the risk of a 
fragmentation of effort and resources, and the less the associated impact and degree of satisfaction. 
b) The means of Community action 
53. Community action against diseases will in particular focus on encouraging cooperation between 
Member States, lending support to their action, promoting in close contact with the Member States 
coordination of their policies and programmes, and making better use of Community policies where 
these relate to public health. Particular attention has to be devoted to the following activities: health 
information, health promotion, health education, health training, cooperation with international 
organisations and third countries, and research. Action by the Community can take, in particular, 
the following forms : 
1) Establishment of a general framework for supporting Member States' policies and programmes 
(networks, joint actions, information exchange systems). It is true that Member States already 
cooperate in certain areas, but this cooperation can now be strengthened. Increased cooperation 
could involve, for example: 
* establishment of common objectives, in particular areas, or for new health threats and 
problems; 
* programmes for exchange of experiences and of health professionals, and for 
dissemination of the most effective practices; 
* standardisation and collection of comparable/compatible data on health, and the promotion 
of systems of health monitoring/surveillance; 
16 
* creation of information networks for the evaluation of different treatments and new 
technologies applied to health, inter alia by disseminating the results of research carried out 
under the Community's framework programmes; 
* compilation of an annual progress report on the health situation within the Community, 
based mainly on reports from each Member State, in order to evaluate activities undertaken 
and make decisions for the future; 
* financial assistance for programmes and pilot projects. 
* assistance to the efforts of Member States to reduce health costs by reducing obstacles 
to free movement of patients between Member States, and by developing the health aspects 
of the use of medicinal products, whilst respecting the Member States' competences in these 
fields. 
2) Better use of Community policies and instruments where these relate to public health. More 
attention will be paid in this respect to the implications for health protection and disease prevention 
when new Community initiatives are introduced in areas other than health. 
c) Selection of areas of activity 
(i) Selection criteria 
54. Based on the considerations above, the following criteria for identifying diseases (or health 
threats) for Community action can be set out: 
1. Diseases that cause, or are likely to cause in the absence of intervention, significant premature 
death (years of life lost) and/or have overall high death rates; 
2. Diseases that cause, or are likely to cause in the absence of intervention, significant ill health by 
having a high prevalence of morbidity or with the potential to cause high morbidity and/or serious 
disability (years of disability-free life lost); 
3. Diseases having significant implications for the quality of life as well as major socio-economic 
effects, such as high health care and treatment costs, or considerable absenteeism and unfitness for 
work; 
4. Diseases for which practicable measures of prevention exist; 
5. Diseases for which there would be added value from the Community undertaking actions, 
particularly through economies of scale. 
55. Whereas application of criteria 1 and 2 may be relatively straightforward, the importance and 
difficulties in using the third criterion must be stressed. In fact "quality of life" is a very subjective 
criterion used to provide descriptions of degrees of disability, distress or pain, or the capacity to 
carry out normal activities. Certain studies have suggested that people consider some health states 
as "a fate worse than death", and such concerns have been taken into account in valuations of the 
global burden of diseases by using concepts such as the quality-adjusted life year. 
56. The selection procedure involves two distinct steps. Firstly, by applying the first four criteria, 
diseases that are of major importance throughout the Community can be identified; these are not 
necessarily the major diseases which the Community should deal with. The latter can only be 
17 
determined as a result of a second selection step involving the attainment of Community added 
value. Finally, which diseases, from among those identified following the two-step procedure, should 
be tackled as a matter of priority can be determined by seeking to maximise the Community added 
value in terms of health gain obtained by providing the necessary coherence and continuation with 
Community activities already undertaken against certain diseases, and by trying to aim, with a given 
action, at as many diseases as possible. 
57. The first step in the procedure involves the examination and analysis of the available data 
concerning a number of important diseases from those listed in the International Classification of 
Diseases. The table in Annex IV contains a list of diseases which have been evaluated according to 
the above criteria. Annex V contains statistical data used in the analysis and discussion on trends 
that follow. The following paragraphs indicate those diseases, which on the basis of the criteria 
should be the focus of Community action, and discuss trends. In addition, Community actions in the 
field of preventing drug dependence, already selected as a priority in Article 129, are described. 
(ii) Major health scourges other than drugs 
Cancer. 
58. The major lifestyle-related cancer is cancer of the respiratory passages and of the lungs. 
Epidemiological evidence shows that this is linked mainly to smoking. In recent decades there has 
been an increase in cancers related to tobacco and alcohol (mainly upper respiratory and digestive 
tract and lungs). 
59. In figure 2 of Annex V the trends towards a Community-average prevalence of lifestyle-related 
health threats and a levelling out of prevalence between males and females (due to increasing female 
smoking) are clearly evident. The most rapid developments are shown in the cases of Denmark and 
the Netherlands but the trend is visible in all countries except Spain which, in contrast, has shown 
a fall in prevalence among females. As far as other forms of cancer are concerned, the trends are 
not quite so clear and, in some cases, do not follow the same pattern. This has to do with two 
factors : first, changes in lifestyle, and, second, the improved capacity for making early diagnosis 
and, thereby, early intervention. Improved capacity for making early diagnosis (combined with 
improved sexual hygiene) means, in the case of cervical cancer, that a downward trend can be 
identified. However, for breast cancer, the opposite trend is evident: in almost all Member States 
the numbers are increasing. It is difficult to give a simple explanation for this development since 
breast cancer cannot be linked easily to lifestyle-related risk factors, although diet is suspected to 
play a role. There is similarly a rise in the overall number of cancers of the digestive organs. Here, 
however, a link to nutrition and changed eating habits is widely seen as a major explanation. This 
and the link between breast cancer and diet are being investigated by the "Europe against cancer" 
programme, by means of a major survey of eating habits in seven Member States. 
Cardio-vascular diseases. 
60. There is a general trend towards a decrease in mortality from cardio-vascular diseases, though 
in Greece and Spain the figures are not so clear-cut as for the other Member States, for reasons 
possibly relating to changes in diet. No unequivocal explanation for this development has been 
produced so far, but there seems to be a certain correlation between reduced prevalence and changes 
in lifestyle. Generally speaking, mortality has dropped most in countries with the biggest decline in 
the number of smokers, the best blood pressure controls, decline in serum-cholesterol levels and the 
biggest increase in physical activity. Moreover, introduction of more efficient methods of treatment 
18 
has had an influence on mortality as well. 
Accidents. 
61. Since 1970 the overall death rate from all kinds of accidents (including poisoning) in the 
Community has declined. With regard to traffic accidents, there has been a significant fall in the 
death and injury rates in most Member States. For example, the mortality rate in France declined 
by one third from 1970-1990, that in Italy by one half and that in the Netherlands by two-thirds. 
On the other hand, in Portugal the injury rate went up considerably after 1985, and in Spain the 
death and injury rates have both increased over the period, though they are still at a relatively low 
level. Moreover it must be stressed that traffic accidents, as shown in Table 5 (Annex V), remain 
the leading cause of death for young people in the Community. 
Suicides. 
62. The overall number of suicides in the Community has shown a rising trend over the last 20 
years. A comparison between the first and the last years available (1970 and 1989) shows that 
Germany is the only country with a significant drop in the number of suicides. The other Member 
States show either a stable pattern or an increase. No definite explanation for these developments 
can be given although societal changes obviously play a role. But differences between political, 
cultural and historical tradition tend to be of importance as borne out by the fact that suicide has 
generally been less common in southern Europe than in certain northern European countries. 
AIDS and other communicable diseases. 
63. Communicable diseases have to a large extent ceased to be a prevalent cause of death in the 
Community, though they still cause significant morbidity. However, the advent of AIDS in the early 
1980s has somewhat changed this picture. The last decade has seen a rapid increase in the number 
of people with this disease in the Community. In 1982, just 86 people were reported as being 
diagnosed with AIDS. By 1990 this number had risen to just under 14,000. The numbers are still 
continuing to increase, though the rate of increase has slowed down. By 30 June 1992 over 69,000 
cases had been reported and by 30 June 1993 the number had risen to nearly 89,000. Making 
allowances for delays in reporting cases, it is estimated that the cumulative total at the end of June 
1993 was over 95,000. Although all Member States are affected, three, namely France, Spain and 
Italy, account for 71% of all Community cases. In northern Member States the largest number of 
AIDS cases are among homosexual men and in southern States among injecting drug users. But the 
proportion of AIDS cases among heterosexuals is continuing to increase throughout the Community. 
No precise figure is available for the number of people in the Community infected with HIV, the 
virus which leads to AIDS. But the WHO has estimated that about 500,000 people are infected. 
64. The recent resurgence of tuberculosis, often associated with AIDS, points also to the need to 
continue to take action against the communicable diseases. 
Other important diseases. 
65. As pointed out in Table 1 above, several other diseases, notably mental illness, musculoskeletal 
conditions and respiratory conditions, produce substantial morbidity in the Community. The ageing 
of populations is likely to increase the prevalence of these conditions. Community action against 
these diseases, though not of the highest priority, will need to be kept under consideration in the 
19 
(4) 
future. 
(iii) Drug dependence 
66. Drug dependence is the only health threat specifically mentioned in Article 129, making it 
automatically a priority for Community public health action. Action on drugs benefits already from 
coordination at Community level; the extent of this multi-faceted problem, with its links to major 
social scourges such as social exclusion and unemployment, and the difficulties encountered by 
Member States in combating its severe effects on society, has led to a series of initiatives being 
taken at Community level over the past few years. The wide range of initiatives adopted by the 
Council and the European Parliament has demonstrated the great importance that they attach to this 
problem and their view that actions to tackle it are needed at the Commumty level. This has been 
reinforced by the singling out of drugs in Article 129 as a major scourge to be given priority by 
Community public health action.. 
67. Important initiatives on drugs include, the Council Resolution of October 1986, and the 
European plan against drugs drawn up by the European Committee to combat Drugs (CELAD) 
adopted by the European Council respectively in December 1990 and which was prolonged by the 
European Council in December 1992. These documents set out a wide range of activities to be 
undertaken. Moreover, the Council adopted in February 1993 a regulation setting up the EMCDDA, 
which is charged with data collection, analysis, comparison and evaluation in the field of drugs, with 
special emphasis in its initial 3-year work programme on demand and reduction of demand for 
drugs. The Community will in the future be able to consolidate its achievements in the field of drug 
prevention, build on the work already carried out, and propose a forward looking programme for 
public health action on drugs and drug dependence. 
(iv) Rare diseases 
68. By definition, rare diseases have less of an impact on society and are responsible for relatively 
little mortality and morbidity. Nevertheless, experience shows that by the very fact of their rareness 
and the consequent lack of information available about them, they can produce significant problems 
for individual countries. Legionnaires disease, Creutzfeldt-Jacob disease and genetic disorders like 
haemophilia, are obvious examples. There could thus be benefits in Commumty initiatives aimed 
at such diseases to complement the efforts of Member States and maximise the exchange of 
information and experience, so that all Member States are assisted in taking appropriate action when 
confronted with an unfamiliar threat. There are other diseases which may be rare in some Member 
States but not in others. One typical example is thalassaemia, which is rife in the south of the 
Commumty. With regard to rare illnesses, therefore, the Community will have to cooperate closely 
with Member States to draw up initiatives likely to generate economies of scale and create solidarity 
between Member States. 
V. CAUSATION OF DISEASES 
69. The groups of diseases mentioned in the previous chapter are those to which Commumty 
measures should be directed. But for preventive action to be as effective as possible, it is not 
enough to direct it just at particular diseases and groups of diseases; it is even more important that 
it is aimed at their underlying causal factors. In considering, therefore, what kinds of measures 
might be appropriate and what priority to give them, it is necessary to look at the key factors 
associated in the aetiology of these conditions. 
20 
70. Of course, as the significant variations of morbidity and mortality between different socio­
economic groups within the Member States would indicate, adverse socio-economic conditions (e.g. 
poor housing, low access to health care, long-term unemployment ) constitute a threat to public 
health. This linkage has been recognised in the recently- launched programme on social exclusion 
(COM (93) 435) which seeks to assess through selected projects the impact of a range of socio­
economic conditions on social exclusion and promote solidarity. Combating these conditions, while 
at the centre of other Community policies, constitutes nevertheless one of the main preoccupations 
of the Community in pursuing its objective to contribute to preventing risks to certain groups, and 
in designing an effective strategy of health protection. 
71. Without attempting to be comprehensive, Table 3 sets out major factors associated with the 
previously identified major health threats. 
Table 3 
FACTORS IMPLICATED IN DISEASE CAUSATION 
DISEASE FACTORS 
Accidents Drunken driving, unsafe behaviour, defective or poorly designed 
products and services, environmental problems 
Cancer Smoking, alcohol abuse, nutrition, genetic factors, exposure to 
radiation and carcinogenic substances 
Cardio-vascular diseases Smoking, alcohol abuse, nutrition, genetic factors, stress, lack of 
exercise 
Communicable diseases, including AIDS Poor hygiene, unsafe water, unsafe sexual behaviour, drug abuse, 
nutrition, contaminated blood 
Drug abuse Socio-economic problems, psychological disorders, stress 
Mental illness, including suicide Socio-economic problems, genetic factors, stress 
Musculoskeletal conditions Poor working environment, physical stress, nutrition, lack of 
exercise 
Respiratory diseases, including asthma Environment problems, including pollutants, smoking, genetic 
factors 
72. It is clear from this table that, quite apart from genetic inheritance, there are a number of other 
common factors, both specific and more general, associated with these diseases. Of the specific 
factors, smoking and alcohol are implicated directly and nutrition also plays a role. More generally, 
environmental problems are directly implicated or to some extent are associated with all of them. 
Some factors are also associated with other significant conditions; nutritional problems, for example, 
are a central factor in diabetes, rickets and osteoporosis; alcohol produces cirrhosis, and smoking 
by pregnant women increases the risks of infant mortality. 
73. In terms of designing an effective strategy of prevention of disease and health protection, the 
fact that several key factors are common to a variety of conditions has important consequences. It 
means, for instance, that measures aimed at preventing people taking up smoking have a significant 
impact on the rates of morbidity and mortality from a range of different conditions, thus greatly 
enhancing their impact. 
21 
74. Measures aimed at eliminating or reducing the impact of particular causal factors related to 
several diseases, employing for example actions in health information, education, and promotion, 
addressing issues such as nutrition, tobacco and alcohol, and aimed at the general public or at 
particular groups such as children or the elderly, can play a key role in the overall strategy and help 
direct limited resources to maximum effect. Such "horizontal" measures form a key part of the 
strategy set out in Chapter VII. However, as well as addressing those factors which are implicated 
in several conditions, the specific features of each disease must not be overlooked. Generally 
speaking, it is difficult to be totally precise about the cause of many diseases. The evolution of 
micro-biology has gradually enabled the identification of the micro-organisms responsible for most 
infectious diseases, but it will be necessary to wait for the mapping of the human genome to know 
which genes are responsible for certain clinical conditions. Moreover, the means of fighting against 
these illnesses will certainly adapt in the future as their precise causation is discovered. 
75. As is the case for the information on the prevalence and effects of the diseases themselves 
across the Community, so information on the major causal factors is also patchy. However, on three 
of the most important, nutrition, smoking and alcohol consumption, some information is available 
from WHO figures which provide a picture of trends across the Community. 
76. On nutrition, figures are available on the proportions of fat and proteins in people's diets. In 
1989 the amount of fat as a percentage of total energy intake ranged from 34% in Portugal to 47% 
in Belgium and that of protein from 10% in Greece to 14% in France. Of more significance, 
however, are the trends which show that while the percentage of protein in diets has not varied 
much since 1970, there has been a considerable rise in fat intake in several countries, notably 
France, Italy, Portugal and Spain. 
77. On smoking there are figures showing total cigarette consumption per capita in the Member 
States on a yearly basis. These show a marked divergence between the trends in the northern and 
southern States. In the period 1976-1990 the total consumption decreased in six northern States by 
between 13.4% in Denmark (from 1801 to 1560 units per year) and 25.5% in the Netherlands (from 
2086 to 1555 units per year), on the other hand there were considerable increases in the southern 
States with, for example, Spain showing a rise of 87.8% (from 1122 to 2109 units per year). This 
north-south divide tends to be borne out by Eurostat data on expenditure on tobacco as a proportion 
of total household expenditure. 
78. The trend of alcohol consumption is virtually a mirror image of that for cigarette smoking. In 
the period between 1970 and 1988 the northern States saw a considerable increase in alcohol 
consumption per head; for example, in Denmark there was an increase of 45.6% (from 6.8 to 9.9 
litres pure alcohol per capita per year) in the Netherlands of 46.4% (from 5.6 to 8.2) and in the UK 
of 43.4% (from 5.3 to 7.6). At the same time in the southern States consumption was falling; in 
Italy it fell by 36.5% (from 13.7 to 8.7) and in France by 21.6% (from 16.2 to 12.7). 
79. It must be emphasised that such data have to be interpreted very cautiously since the baselines 
for Member States vary considerably. The WHO data on alcohol as a percentage of total energy 
intake, for example, show that in 1989 there was a considerable range between Member States from 
3.% in Greece to 8.% in Germany. The main value of such figures is in indicating trends which in 
turn can reveal current and potential problems and highlight areas for intervention. 
22 
VI. THE NATURE AND EXTENT OF COMMUNITY INVOLVEMENT 
a) General approach 
80. The health sector is a broad domain of organized activity , the workings and effects of which 
directly and profoundly influence one of the most cherished possessions of the individual, namely 
his or her health. Traditions, practices and the legal and administrative organisation of public health 
services and systems are so varied as to render meaningless any talk of unification or harmonization 
of policies in this domain. 
81. The role of the Community is to underpin the efforts of the Member States in the public health 
field, assist in the formulation and implementation of objectives and strategies, and contribute to the 
continuity of health protection provision across the Community, setting as a target the best results 
already obtained in a given area anywhere in the Community. 
82. Needs in the field of public health across the Community are vast and there is no question of 
the Community seeking to meet them all. Rather, the Community will carry out actions that yield 
the highest possible added value from the limited resources available, using instruments and 
measures that are deemed to have the greatest impact. The Commission will seek to ensure that 
actions at the policy and strategy level, aiming at as many selected diseases as possible, are given 
top priority, sufficient means, and clear objectives. The Commission will accord priority to large-
scale, wide-impact projects involving as much as possible governmental organisations and non­
governmental organisations with a proven record in their respective fields. The Commission will also 
ensure that instruments in other policies are used for, or contribute to, health protection, and any 
adverse impact from other policies is eliminated by keeping a "health watch" at all stages of drafting 
of pertinent instruments and programmes. Finally, the Commission will be ready to respond to 
Member States' requests for contributions to cooperation between them, and will enlist, when it is 
appropriate, the aid of international organisations competent in health matters. 
83. Table 4 shows, in a matrix form, the kind of action that can be undertaken at Community level 
for a range of identified health threats expressed either as a disease or group of linked diseases or 
as a causal factor. Of special importance are activities to support Member States' actions and 
promotion of coordination of their policies and programmes , cooperation with international 
organisations and third countries, information, education, health promotion, training and research, 
which are further discussed below 
23 
TABLE 4 
POSSIBILITIES FOR COMMUNITY ACTION 
TYPE OF ACTION 
HEALTH 
THREATS AND 
DISEASES 
Tobacco 
consumption 
Drug abuse 
Alcohol abuse 
Lack of exercise 
Poor diet 
Cancer 
Diseases of the 
circulatory system 
Respiratory diseases 
Congenital 
ab normalities 
Perinatal conditions 
Accidents 
Muscolo-Scetetal 
problems 
Visual problems 
Auditory problems 
Mental disorders 
suicides 
Nutrition related 
disorders Health data 
indicators 
**** 
**** 
**** 
** 
**** 
**** 
**** 
*** 
*** 
*** 
**** 
** 
** 
** 
**** 
** Surveillance 
Monitoring 
* 
*** 
* 
* 
* 
** 
** 
*** 
** 
** 
*** 
* 
* 
* 
* 
* Health Information 
Public S pecific 
groups 
*** ** 
** *** 
*** ** 
** ** 
*** *** 
*** **** 
*** **** 
** *** 
** *** 
** *** 
**** *** 
*** *** 
** ** 
** ** 
* ** 
* ** Health 
education / 
promotion 
*** 
**** 
*** 
** 
*** 
**** 
**** 
** 
** 
• * 
**** 
** 
** 
** 
** 
** Training of 
health 
professionals 
* 
**** 
** 
* 
** 
*** 
*** 
*** 
** 
** 
*** 
** 
** 
** 
** 
** Cooperation 
between 
Member 
States 
**** 
**** 
*** 
* . 
*** 
• ** 
*** 
**** 
*** 
** 
*** 
** 
• * 
** 
** 
** Policy 
co-ordination 
**** 
**** 
** 
* 
** 
*** 
** 
**** 
* 
** 
*** 
* 
* 
* 
* 
* Strategy 
formulation ft 
implementation 
**** 
**** 
** 
* 
** 
**** 
*** 
**** 
* 
* 
*** 
* 
* 
* 
# 
* Use of 
instruments 
in other 
policies 
**** 
**** 
**** 
* 
**** 
**** 
*** 
**** 
* 
* 
**** 
** 
• * 
** 
** 
** Financial 
support 
*** 
**** 
*** 
** 
*** 
**** 
** 
*** 
** 
** 
** 
** 
** 
** 
** 
** Surveys, 
studies 
* 
*** 
*** 
** 
**** 
**** 
*** 
*** 
** 
** 
**** 
** 
** 
** 
*** 
*** Cooperation 
with 
intern ationasl 
organisations 
and third 
countries 
** 
**** 
** 
** 
** 
**** 
*** 
*** 
** 
*** 
** 
** 
** 
** 
** 
** Other 
specific 
preventive 
actions 
*** 
**** 
*** 
** 
** 
** 
**** = HIGH *** = MEDIUM ** = LOW * = NONE 
24 
TABLE 4 
POSSIBILITIES FOR COMMUNITY ACTION 
TYPE OF ACTION 
HEALTH 
THREATS AMD 
DISEASES 
AIDS 
Other communicable 
diseases 
Rare diseases 
Food bome diseases Health data 
indicators 
**** 
**** 
*** 
*** Surveillance 
Monitoring 
**** 
**** 
*** 
*** Health Information 
Public Specific 
groups 
** **** 
** **** 
* *** 
** ** Health 
education / 
promotion 
**** 
** 
* 
** Training of 
health 
professionals 
**** 
**** 
*** 
*** Cooperation 
between 
Member 
Sûtes 
**** 
**** 
**** 
*** Policy 
co-ordination 
**** 
**** 
*** 
*** Strategy 
formulation te. 
implementation 
**** 
**** 
** 
** Use of 
instruments 
in other 
policies 
*** 
** 
* 
*** Financial 
support 
**** 
**** 
** 
** Surveys 
studies 
**** 
**** 
*** 
*** Cooperation 
with 
intemationasi 
organisations 
and third 
countries 
**** 
**** 
*** 
** Other 
specific 
preventive 
actions 
**** 
*** 
** 
** 
**** = HIGH *** = MEDIUM ** = LOW * = NONE 
25 
b) Consultation and participation mechanisms 
84. Article 129 provides for the consultation of the Economie and Social Committee and of the 
Committee of the Regions. Moreover, Community instruments of binding character provide for 
consultation and participation mechanisms in relation to programmes and measures adopted by the 
Community in the field of public health. Apart from these mechanisms, the Commission intends to 
obtain additional expertise in order to ensure that the best possible consultation and participation 
machinery is available to give guidance and feedback as regards Community activity on health 
protection, whilst streamlining and consolidating the existing structure of committees and working 
groups. 
85. The Commission will provide for the establishment of appropriate consultation and 
participation mechanisms in the context of the implementation of this public health framework. In 
this regard the respective roles of health professionals and non-governemental organisations will be 
recognised. 
c) Support to Member States' action and promotion of coordination 
86. The Commission intends to base its support for Member States on specific actions, which it 
alone is able to implement, in particular by promoting the exchange of experience and views and 
the preparation of actions that can be implemented through a variety of instruments in different 
sectors. 
87. With regard to areas of activity in which the Commission believes there is value in launching 
new and innovative actions, the following considerations apply: 
(i) The comparison and evaluation of prevention policies against health threats though difficult, is 
essential in order to avoid an uncoordinated approach which can have an adverse impact on the 
choices and decisions of public health authorities. The Commission can play a decisive role in this 
respect by undertaking large-scale cost-effectiveness analyses^ based in particular on models and 
tools made available to it by epidemiological science,and by formulating proposals for measures and 
programmes aimed at strengthening the defences against diseases. 
(ii) The Commission will seek to assist Member States in improving standards of health promotion 
and disease prevention. Some Member States have undoubtedly attained a high level of protection 
in some areas, and since the aim is to achieve levels of protection at the best level existing in the 
Community, the Commission should try to provide the information necessary to correct 
shortcomings, taking as its reference point those Member States' policies and programmes which 
are the most advanced in this respect. A primary aim in this area will be the establishment of 
interconnected networks of competent centres for the monitoring and control of diseases, using 
appropriate data, criteria and methods. Efforts towards this goal are already underway concerning 
communicable diseases, and appropriate iniatives will be taken concerning other diseases, building 
on systems and arrangements already existing, e.g. on cancer. 
(iii) Member States' attitudes towards persons from non-member countries vary considerably with 
regard to health protection requirements and to the health protection afforded to them. Policies in 
this area need to be coordinated and the Commission intends to launch appropriate initiatives on this 
subject. In order to achieve these objectives there is a need for the greatest possible transparency and 
the Commission will need to have recourse to appropriate advice and to consult widely in order to 
76 
plan effectively, to communicate its messages, and to promote dialogue on the issue of migrants and 
health. 
d) Information, Education and Health Promotion 
88. Activities directed towards the general public and specified sub-groups can be categorised 
as health information, health education or health promotion. It has become clear over the years that 
the precise meaning of each of these terms varies according to the particular cultural and linguistic 
context. 
89. Health Information involves the communication, often to the general public, but also to 
specified groups, of information on health-related matters. The content will normally be relatively 
general rather than personal, since it is unlikely that the recipients can be identified precisely. The 
medium may be paper (leaflets etc.) print (advertisements and articles) audiovisual (TV and radio) 
or, less often, personal (talks and lectures by health experts for example). 
90. Health Education implies the provision of a body of knowledge concerning health to a defined 
target group, using learning opportunities. The process will include interaction with and feedback 
from the recipients and the process cannot be said to be completed until the target group has 
demonstrated a change in awareness which should include, and go beyond, the knowledge of a 
number of factual elements. The critical point is that the educator undertakes to deliver a certain 
set of information and knowledge, and will adopt various approaches to ensure that it is achieved. 
It should be noted that while this process is typically associated with school-based education of 
children, it is not confined to this group. Responsibility in this field depends on the administrative 
structures in the individual Member States: both health and education departments may be involved, 
and other ministries may also have a say. 
91. Health Promotion has been described as applied health information. In other words, where 
health information and health education attempt to provide the target with the information and tools 
necessary for a healthy lifestyle, health promotion will actively seek to modify attitudes, behaviour, 
and environments, to enable the pursuit of a healthy lifestyle. Techniques may include legislation, 
economic incentives, modifications in various ways of the environment of the target group in order 
to promote healthy lifestyles. Health promotion measures and those leading to the long-term 
improvement of social and economic conditions, have to go hand in hand, as health promotion is 
a complex task interwoven with the entire social and political situation. It is not sufficient to act 
unilaterally on health-related problems, nor to limit efforts to people at high risk; rather, the whole 
community has to be involved in a joint effort that gives a continuing sense of collaboration and 
participation to everybody and leads to the long-term improvement of general living conditions. 
92. Health promotion and health education can be considered as general subjects which are taking 
place in a large and diverse area, (family, school, work, community), cover many lifestyle-related 
diseases or accidents (cancer, AIDS, drugs, cardiovascular diseases, accidents, etc), and aim to 
change risk behaviour (smoking, alcohol, nutrition, drug abuse, lack of physical exercise, etc). The 
social and cultural differences between and within Member States have to be carefully assessed in 
undertaking Community health promotion and health education activities,particularly as regards 
nutrition and drug abuse. 
93. The different approaches needed in a diverse and complex society such as the European 
Community should, however, never lead to a scattered approach. On the contrary, the various 
27 
approaches should reinforce each other in order to ensure the maximum effectiveness of all the 
health promotion and health education actions. This can be done by linking the various approaches 
at the different levels (European, national, regional, and local). An effective organisation and 
coordination of health promotion and health education actions at all levels, as well as careful 
planning and evaluation of the actions, within the context of an overall plan, is a prerequisite to 
ensure maximum benefits from the efforts expended in the promotion of health. The Commission, 
therefore, is reviewing existing programmes to ensure that where there are actions of a similar 
nature, such as health promotion and health education, these will be regrouped together so as to 
avoid duplication of effort and to improve efficiency. 
94. In implementing health promotion and health education the role of the Commission will be to: 
- facilitate the exchange of information and models of good practice by networking, preparation 
of information packages, manuals, and workshops; 
- lend support by providing appropriate incentives; 
- initiate, generate, and coordinate, as necessary, activities at Community level. 
95. An appropriate use o£ the resources and expertise available in the Member States of the 
Community will be made in order to increase the effectiveness of health promotion and health 
education actions. 
e) Research 
96. Apart from Articles 130f to 130q on "research and technological development" which cover 
all research activities, Article 129 gives the Community a clear mandate for research in the field of 
disease causation and transmission. Actions under this public health framework should make full use 
of the results obtained under the Community's framework programmes for research. 
97. Research on biomedicine and health (BIOMED) in the context of the current Community 
programme of research and technological development, runs until 1994 with a budget of over 130 
millions ecus. 
98. Current research covers four main areas: 
coordination of research on prevention, care and health systems, 
major health problems and diseases with an important socio-economic impact, 
human genome analysis, 
medical ethics. 
99. AIDS figures prominently among the major health problems. The other major health problems 
covered by this programme are cancer, cardiovascular disease, mental illness and neurological 
disease and the ageing process and age-related health problems. In all these areas links with action-
oriented activities are being strengthened. 
100. Discussions are currently underway concerning a fourth framework research programme on the 
basis of a formal Commission proposal (COM(93)276). The Commission published on 6 October 
1993 a working document (COM (93)459) concerning the scientific and technological content of the 
specific programmes implementing the 4th framework programme. It is now being considered by 
28 
the European Parliament and the Council, and it proposes the following headings for research in 
biomedicine and health during 1994-1998: 
AIDS, tuberculosis and other infectious diseases; 
cancer; 
pharmaceutical research; 
neurosciences and brain research; 
prevention, occupational health, risk factors, and public health research; 
epidemiology of illnesses with a major socio-economic impact; 
cardiovascular diseases; 
human genome analysis; 
health services research; 
biomedical technology and engineering; 
biomedical ethics. 
101. Another area where significant developments in Community research over the next few years 
are expected is that of the Telematics Programme for Health Care (formerly AIM). The activities 
in AIM, with a budget of nearly 100 million ecus for the period 1991-1994, are intended to improve 
the quality and cost-effectiveness of health services by the use of "telematics", i.e. the combination 
of informatics and telecommunications. 
102. In order to ensure that a coordinated effort is made and that existing and future Community 
research programmes cover adequately the subjects of health promotion and disease prevention, the 
following conditions should be met: 
the identification based on clear priorities agreed at Community level of those aspects of public 
health that need stimulus and promotion through research, 
coherence between public health actions and research activity, 
a clear strategy covering those matters relevant to public health topics, 
the step by step establishment of appropriate structures e.g. networks. 
the proper dissemination of research results and their impact on decision at Community level 
and Member State level 
f) Training of Health Professionals 
103. Health professionals in different settings (general practice, hospitals, schools, occupation, 
leisure) have a key function in the transmission of health education and health information messages 
to the Community. This has already been demonstrated in the case of the fight against cancer and 
AIDS, with important activities being undertaken in the framework of the relevant Community 
programmes. It is the intention of the Commission to pursue work in this area in order to : 
(i). Increase the awareness of health professionals about the important role they can assume and 
about how they can contribute to the prevention of major diseases. 
(ii). Increase their grasp of issues relevant to the prevention of diseases with a multi-cultural 
dimension, e.g. the role of nutrition, migration (e.g. related to thalassaemia and HIV), and 
29 
their knowledge of conditions that are gaining in importance (e.g. tuberculosis). 
104. To this end, taking into account both the Community's guidelines on education and training, 
as set out by the Conimission in May 1993 (COM(93)183) and the experience acquired through 
Community action programmes, such as ERASMUS, FORCE and COMETT, the Commission will 
undertake, where appropriate under these action programmes, the following : 
(i) Promotion of exchange of information between Member States on current training courses and 
schemes notably in relation to toxicodependency, but also including alcohol and medicines, 
nutrition, and sexually transmitted diseases. 
(ii) Coordination and recommendations on training programmes for health professionals, in close 
collaboration with the competent authorities, learned institutions, and the committees and 
associations concerned. 
(iii) Encouragement of exchanges of experiences on teaching methods and didactic materials in 
relation to the prevention of major health scourges and on the evaluation of effectiveness of 
those teaching methods and materials. 
(iv) Inventory and evaluation of existing methods and practical applications on how to improve 
accessibility and availability of information and materials aimed at health professionals, in 
relation to the prevention of major health scourges. 
(v) Information and promotion of awareness of doctors, nurses and social workers on specific 
conditions uncommon in their respective Member States, but which, as a result of growing 
migration and travel , are becoming increasingly important in the Communitya such as 
tuberculosis in migrants, HIV and STDs in tourists, and thalassaemia in people of 
Mediterranean origin. 
g) Cooperation with international organisations and third countries 
105. Whilst cooperation with third countries and international organisations is specifically mentioned 
in relation to public health in Article 129, cooperation in general has already been undertaken by 
virtue of Article 228 of the EEC Treaty which provides for the conclusion of agreements between 
the Community and one or more States or an international organisation. The Treaty also states that 
the Commission has to ensure the maintenance of all appropriate relations with the organs of the 
United Nations, of its specialized agencies, and shall also maintain such relations as are appropriate 
with all international organisations (Art. 229). The EEC Treaty also provides in Article 230 for the 
establishment of all appropriate forms of cooperation with the Council of Europe and in Article 231 
for cooperation with the Organization for Economic Cooperation and Development (OECD). 
106. The Commission has already long-standing collaboration with third countries and with several 
international organisations in the field of public health. In the future the onus must be on increasing 
the cooperation with them such that maximum benefit can be drawn for all the parties involved. 
To foster cooperation of the Community with third countries and international organisations in the 
field of public health it is necessary to have good knowledge of on-going and planned cooperation 
between Member States and third countries and international organisations. This will help to avoid 
duplication of efforts and lend support to the actions undertaken by Member States. 
30 
(i) International organizations 
107. A relatively large number of organisations, both governmental and non-governmental have 
health on their agenda. The main organisations concerned are: WHO, Council of Europe, 
International Organization for Migration (IMO), UNESCO, International Atomic Energy Agency 
(IAEA), OECD, ILO, FAO, United Nations international Drug Control Programme (UNDCP), 
International Federation of Red Cross and Red Crescent Societies, and the International Council on 
Alcohol and Addictions. 
108. Agreements in various forms have been established with most international organisations, and 
in one instance the Community has become a full member of an international organisation (FAO, 
1991). With the exception of WHO, whose activities encompass all health matters, other 
international organisations only deal with specific health issues as they relate to their objectives. 
However, in the case of the Council of Europe, which has links in many areas with the Community, 
there has been an expansion of its role in the public health field, particularly since a number of 
countries of Central and Eastern Europe have become members of that organisation. 
109. The object of fostering cooperation is two-fold: 
- to strengthen the public health actions within the Community, as well as those undertaken 
outside the Community but which have an impact on it; 
- to ensure that the Community plays an increased role in the public health field at. the 
international level. 
WHO 
110. Cooperation with WHO is based on two exchanges of letters with the Commission (1972 and 
1982). This cooperation covers the Organization as a whole, as well as its Regional offices, and in 
particular the European Office, and the International Agency for Research on Cancer (IARC). At 
operational level, intensive working relations have been developed between the Commission and 
WHO in different areas. These include the organisation of joint activities in specific areas. Of 
particular importance is technical expertise provided by WHO to the Commission services, to help 
to reply to specific demands, as for example development assistance and the provision of 
humanitarian emergency aid. Cooperation in the cancer field with I ARC is already extensive. A 
review of the current WHO-CEC collaboration has been transmitted to Council (COM(93) 224 
final). It is the Commission's intention to arrange a further exchange of letters with WHO in order 
to update, improve and expand cooperation on specific issues. 
Council of Europe 
111. With the Council of Europe, cooperation is based on the EEC Treaty and has been amplified 
by a 1987 agreement. In the public health field, cooperation covers matters such as blood, organ 
transplantation, health education, youth and health promotion issues and health and sports, in 
particular doping. There is also close involvement in the workings of the European Health 
Committee and the European Pharmacopoeia and, especially, in action on drugs where close 
cooperation exists between the Commission and the Pompidou Group and which will be further 
extended through the establishment of the EMCDDA. In addition, enhanced collaboration with the 
Council of Europe in the health fields appropriately directeda could promote cooperation with Central 
31 
and Eastern Europe thus contributing to the fulfilment of the objectives of paragraph 3 of Article 
129. 
112. The Commission is carrying out an examination of its cooperation with the Council of Europe 
in public health, and will be making the results of this examination available in due course. 
Consideration will be given to proposing the introduction, into the draft Council of Europe 
conventions on health, of clauses permitting the European Community to become a party to these 
conventions, without the need for the negotiation and ratification of specific protocols. 
Other International Organizations 
113. IOM: Cooperation is ongoing on the issue of migration and health; 
UNESCO: AIDS and drug education are covered and will be further developed. 
ILO: Joint activities are undertaken on drugs and alcohol at the workplace. Initiatives are being 
developed on smoking, health education and promotion also involving workers' families. 
FAO: A joint conference on nutrition and health has been organized and more joint activities 
are envisaged to implement its results. 
UNDCP: Cooperation on drug demand reduction is being stepped up. 
RED CROSS: Humanitarian health assistance has been provided through the International Fed­
eration of Red Cross and Red Crescent Societies and will continue in the future on such issues 
as blood supply and quality, AIDS prevention, etc. 
OECD: Cooperation is ongoing in the field of the health aspects of the environment, (chemical 
safety in particular), and will be further developed on the subject of health statistics. 
IAEA: Close cooperation exists in the field of radiation protection. 
Nature of increased cooperation 
114. The nature of increased cooperation with international and non-governmental international 
organizations could take three forms: 
in matters of Community competence, the Commission could ask international organizations 
to carry out specific tasks for the Commission in areas where these organizations have a 
mandate and proven expertise (joint projects). 
in areas reserved for cooperation between the Member States, the Commission can enlist the 
help of such organisations, in conducting joint programmes and actions which benefit some or 
all of the Member States. 
in areas where the international organisations conduct their own programmes or actions, which 
are not priority matters for the Commission or the Member States, the Commission may provide 
assistance, if such programmes and actions are of interest to the Community. 
(ii) Cooperation with third countries 
115. Cooperation with third countries will take into account the present and future links existing 
between these countries and the European Community. There are a number of countries having 
formal agreements with the Community; in some of these agreements health protection is 
specifically covered. It is intended to examine with these countries what emphasis will be accorded 
to health matters under these agreements. 
116. According to the conclusions of the European Council of Copenhagen (1993) Community 
programmes should be opened up to the countries of Central and Eastern Europe having association 
32 
agreements with the Community. This should lead to the development of practical links with these 
countries to complement the assistance already provided by the Community. The possibility of 
opening action programmes for their participation will be jointly considered with these countries. 
Similarly cooperation with countries that have applied for Community membership should permit 
the identification of topics of mutual interest, and their gradual involvement in a number of on-going 
activities. 
117. In the framework of its relations with developing countries, the Community participates in 
cooperation programmes in the field of public health. Emphasis is placed in supporting, by means 
of various financial instruments, health system reform and actions aimed at satisfying basic needs 
of the populations concerned, in particular the most vulnerable groups. Assistance is also extended 
to the fight against major endemic diseases, and in particular sexually transmitted diseases and 
AIDS. Collaboration, in the context of public health programmes, present and future, will be stepped 
up, in order to share experiences and adopt coherent strategies on health issues of importance both 
to the Community and the developing countries, such as AIDS and drug dependence. 
VII. FUTURE ACTION IN THE FIELD OF PUBLIC HEALTH 
118. The strategy chosen for selecting health threats for action at Community level, in addition to 
what is and shall be undertaken in the research area, points to the pursuit by the Community of a 
mix of (i) actions of a general nature benefitting the fight against many diseases, for persons of 
different age groups, socio-economic categories, sex, etc. such as health data and surveillance, health 
information, education and promotion, (ii) actions that are disease-specific and need, for maximum 
efficacy, to be narrowly focussed, ensuring at the same time a sensible continuation of major current 
programmes which have proved their worth and have brought together public authorities, many 
interest groups and individuals across the Community in the best demonstration of the principle of 
subsidiarity. 
119. Category (i) above directly responds to the challenge of undertaking action against all the major 
health scourges previously identified, in a way that promises to yield maximum health gain from 
the involvement of the Community, and stands to benefit both those who shape and take decisions 
and, the citizens of the Community. Category (ii) will help to facilitate the imput of interest 
groups and experts and better enlist and organise them in the fight against specific diseases. 
120. Annex IV shows for each identified health threat and disease what, in qualitative terms, is 
expected to be the impact of involvement by the Community. Community programmes with actions 
of a general nature, listed, among others, in Table 4, will not only yield added value in respect of 
these health threats and diseases, but, also, in respect of other threats and diseases. This is the case 
for example of health information on nutrition and on smoking in relation to cancer and to cardio­
vascular disease. Finally, specific actions in the context of programmes for particular threats and 
diseases will complement and reinforce the previous actions and will ensure that no opportunity is 
lost in tackling the selected diseases in a comprehensive and coherent manner. Both disease specific 
and "general action"programmes, will be introduced by using the legal instruments foreseen by 
Article 129, and their aims furthered by measures based on Article 129, or indeed other appropriate 
Articles of theTreaties. 
121. In terms of major health scourges, the above considerations lead the Commission to conclude 
that a number of them can sufficiently be addressed at present by existing programmes and 
instruments, and by future actions of a general nature. These are cardio- and cerebro-vascular 
33 
disease, mental disease, congenital defects, perinatal conditions, and musculoskeletal disorders. The 
Commission intends to keep the situation as regards these diseases under review, so as to be able 
to undertake specific actions if this appears to be appropriate. Moreover, for those programmes and 
measures that have been selected, the Commission intends to introduce more systematic evaluation 
mechanisms, involving substantive as well as management measurements. The former will include 
estimation of decreases in the occurrence of risk factors and alteration in risk behaviours and 
attitudes ; the latter will enable the drawing up of conclusions on whether preset goals have been 
achieved and what modifications are needed, to identify the causes of success or failure, and to 
define ways by which goals can be achieved with minimum costs, and maximum results obtained 
with given resources. 
122. The areas singled out as a matter of priority for future Community action in the field of public 
health can now be determined. These areas may be the subject of Commission proposals for 
comprehensive multi-annual programmes which set clear objectives and will respect the principles 
already outlined in this document, including subsidiarity. These programmes would be introduced 
over a three-year period, and on the basis of experience gained, would last IbrTive years. The 
programmes would be on the following topics: 
- Health promotion, education and training 
- Health data and indicators, and monitoring and surveillance of diseases 
- Cancer 
- Drugs 
- AIDS and other communicable diseases 
- Intentional and unintentional accidents and injuries 
- Pollution-related diseases 
- Rare diseases 
In the light of experience and developments in the incidence of diseases in the Community, the 
Commission may propose programmes on other health threats. 
34 
ANNEX I 
OVERVIEW OF PREVENTIVE POLICIES IN THE MEMBER STATES 
1. BELGIUM 
(French Community). 
Present priority areas are: AIDS, drugs, elderly people, immigrants and vulnerable groups. The 
preventive actions include health education, school health services, actions against drugs, AIDS and 
mental health problems. Moreover, long existing programmes on vaccination, hygiene and sports 
injuries continue to be pursued. 
(Flemish Community) 
A comprehensive Health Promotion and Prevention Strategy has been elaborated, the key elements 
of which are: 
- mid-term priority setting; 
- coordination of local and regional initiatives which fit well with the overall, national and 
community context; 
- integration of sectorial approaches into a general health promotion frame; for example school 
health, mental health, drug prevention, and child and family issues; 
- implementation of legal provisions (e.g. early notification of diseases, vaccinations); 
- provision of adequate resources for specific preventive action, notably in the field of AIDS, 
cancer, cardiovasuclar diseases, perinatal mortality , accidents, tranmissible diseases and mental 
health; 
- action by the authorities assisted by other partners such as the "Flemish Health Promotion 
Institute" which, since 1991, constitutes an important forum for all organisations concerned with 
health promotion and education; 
- other coordination mechanisms have also been set up in specific fields , such as AIDS, tobacco 
prevention, alcohol and drugs, cancer, etc. 
- monitoring, surveillance and quality control work in public health including data collection 
and analysis of trends. 
2. DENMARK 
Apart from a number of preventive services carried out by the established Health Care System, the 
Danish prevention policy is based on the document "the Health Promotion Programme of the 
Government of Denmark". This programme, published in 1989, gave priority to programmes on 
cancer, cardiovascular disease, accidents, psychological problems and musculoskeletal diseases. In 
addition to these priorities, Denmark has specific programmes on drugs and AIDS as well as on 
asthma and allergic diseases. 
The Ministry of Health is the coordinator of all actions in this area taken by government agencies, 
and strives to integrate prevention considerations into other policies being implemented in Denmark. 
35 
To this end, a number of coordinating bodies have been set up, all chaired by the Ministry of 
Health. 
As regards funding, preventive issues are financed from tax revenues. 
3. GERMANY 
Responsibility for health issues lies almost entirely with the Lander and apart from Federal 
programmes on cancer, AIDS, and drugs, all other health prevention actions as well as all other 
health related activities are carried out in a decentralised manner by the Lander. In support of the 
above activities the Federal Government launched in 1993 a programme on Health Research called 
"Health Research to the year 2000". This programme deals with lifestyles, nutrition and the 
environment as well as care for groups at special risk namely children, young people, women and 
the elderly. 
A number of Federal advisory bodies have been set up to deal with Health and Prevention issues, 
foremost of which is the health Bundesgesundheitsrat (Federal Health Council).The Council of 
professionals advises on concerted actions and the Federal Health Research Council on research. 
Other advisory and expert groups exist for specific diseases. 
Preventive activities are financed from tax revenues at the federal, Lander, and municipality level, 
from health insurance contributions, as well as from contributions from companies and from various 
other sources. 
4. GREECE 
Prevention policy in Greece follows the orientations of WHO's "Health for all by the year 2000", 
with emphasis being placed on the selection of priorities and on the involvement and cooperation 
of public and private bodies. Current areas of priority include cancer, AIDS, cardiovascular disease, 
blood and blood products supplies, blood-related hereditary diseases, accidents, drugs, mental 
diseases, infectious diseases. 
Action on cancer, aided by the Commumty, focuses on nutrition , tobacco and screening 
programmes, and on developing a national cancer register. The fight against AIDS is carried out 
mainly through special programmes of information research and social assistance. Particular efforts 
are made for encouraging voluntary blood donations, with compulsory controls being made on 
donated blood for hepatitis B and C and for HIV, and on the prevention of thalassaemia and 
haemophilia. Increasing attention is directed towards the collection and utilisation for prevention 
purposes of information on accidents on the road, home, and during leisure activities, and 
programmes of health education have been launched using in particular the concept of the Health 
Promoting School. Action against infectious diseases includes systematic vaccination and compulsory 
notification, as well as ad hoc measures, e.g. on tuberculosis and malaria The elderly benefit from 
a range of health information and education actions, and from measures designed to provide 
assistance at home. Finally, training of health professionals on prevention and on the problems of 
migrants is gaining importance. 
Policy is formulated by the Ministry of Health and Social Security, following advice by the Central 
Health Council which comprises experts from across the health professions. Specialised quasi-
governmental agencies and bodies exist for the implementation of measures and programmes against 
certain diseases and health threats. 
Financing of action programmes and research is mostly provided by the Ministry of Health budget, 
but there are also contributions from tobacco taxation and nation-wide donation campaigns. 
36 
5. SPAIN. 
The general health policy objectives fall into three categories: promotion of healthy lifestyles, 
prevention of environmental risks to health and improvements to the health care system. 
Concerning the promotion of healthy lifestyles, public health measures are aimed at reducing tobacco 
consumption and its harmful effects on health, encouraging physical exercise, reducing the harmful 
effects of alcohol, reducing drug abuse and dependency on harmful substances and developing diets 
suited to individual needs. The measures for the prevention of environmental risks are aimed at 
reducing biological, physical and chemical risks as well as preventing hazards at work and accidents. 
Finally, improving the health care system includes the extension of public health care, developing 
primary health care, special care, maternal and infant care, development of oral hygiene, mental 
health care and the rehabilitation and geriatric care systems. Specific disease prevention programmes 
include programmes on cardiovascular diseases, cancer, AIDS, accidents and zoonoses. In addition 
to these programmes, two horizontal programmes are being carried out on health promotion and 
health education. 
Responsibility for the execution of prevention policies lies with all administrative levels: the 
national, regional and the local levels and a number of advisory bodies assist in the formulation and 
implementation of the various policies. Legal provisions regulate areas like vaccinations, notifiable 
diseases, food hygiene, atmospheric protection, protection against physical agents and protection 
against hazards at work. Additionally a comprehensive set of legal instruments, regulates tobacco: 
a ban on advertising, health warnings, nicotine and tar contents, a ban on sales to children and 
restrictions or bans on consumption. 
6. FRANCE 
The national prevention policy contains three elements: i) action directed at all determinant issues 
affecting health ii) medical prevention (vaccination, screening and prophylaxis) iii) and action 
directed at specific target groups (school children, the old, pregnant women, the disabled, and young 
people with adaptation difficulties); 
In 1991 a High Level Committee on Public Health was established by the Minster for Health in 
order to give advice on public health questions and policy . This Committee is at present re-shaping 
public health policy on the basis of WHO's Health for All Strategy. Besides that Committee, 
prevention and health promotion activities are carried out by specific advisory bodies and by local 
authorities. 
Legal obligations cover the following areas: vaccinations, medical examinations, before marriage, 
during pregnancy and post-natal for mother and child, drug use, tobacco and alcohol advertisements, 
and declaration of communicable diseases. 
Prevention programmes on specific diseases and health threats concern AIDS, drugs and drug abuse, 
tobacco and alcohol, use of pharmaceuticals, STD's, cancer screening prevention and dental 
problems. General prevention programmes are directed towards elderly people, women, young 
people, the handicapped and also concern the integration of health aspects in urban development and 
schools. 
As regards funding, prevention activities are financed from a combination of tax revenues and health 
insurance contributions. 
7. IRELAND 
37 
The objectives of the national prevention policy include: prevention of infectious diseases, early 
detection of health defects in children, achieving significant improvements in the level of oral health, 
and reducing the incidence of disease attributable to smoking, alcohol abuse and other lifestyle-
related factors. 
The Irish Government in 1988 adopted a policy aimed at health promotion, and established new 
health promotion structures including a Cabinet sub-committee on health promotion to provide an 
effective mechanism whereby decision making in areas of public policy with an impact on health 
can be made on the basis of a health perspective. Preventive actions in Ireland include immunisation 
programmes, notification, diagnosis and hospital services for infectious diseases, monitoring of 
tuberculosis,cervical screening, maternity, infant care and child health, dental care, AIDS, drug 
abuse and tobacco. 
Towards the end of 1993 the Ministry of Health will propose a national health strategy which will, 
in particular, include a strategic plan for health promotion, map out the current Irish health status 
and set out national goals and targets for specific improvements, along with a strategy for achieving 
them. 
8. ITALY 
Preventive activities in Italy are mainly concentrated on four issues. Environment and 
health,lifestyle-related problems, health protection at work and the prevention of infectious diseases. 
As regards Environment and Health, activities are increasingly being carried out by the European 
Centre of Environment and Health which was set up by mutual agreement between the Regional 
Office for Europe of WHO and the Italian Government. On lifestyle related diseases, Italian policy 
concentrates on nutrition, smoking, drugs, and AIDS. Concerning health protection at work, the 
basic law (N° 46 of 5 March 1990) governs health and safety at technical installations, equipment, 
substances and buildings, and has been supplemented by decrees transposing EC Directives based 
on Art. 118A of the EEC Treaty. For the prevention of infectious diseases, Italy has over the last 
two years introduced a new system for the prevention and reporting on such diseases. The new 
system means that such diseases can be identified better and more quickly ensuring a rapid flow of 
information to and from the Ministry of Health so that, where appropriate, immediate action can be 
taken and information exchanged with International Health Organisations. 
Responsibility for the prevention activities lies with a number of institutions, notably the Ministry 
of Health, The National Health Service, Local Health Authorities and the Drugs Addiction Services. 
9. LUXEMBOURG 
Since the 1970's preventive action has been an integral part of the overall Health Policy in 
Luxembourg. This was reflected in the re-organisation of the Government Health Department in 
1980 whereby special divisions were set up for prevention. The most important programmes are the 
programmes on drugs, tobacco, alcohol, on cardio-vascular diseases, and on cancer. In addition to 
this, a special programme has been launched to promote healthy nutrition and healthy lifestyle. 
Activities on prevention are coordinated by the Ministry of Health, with the other Ministries taking 
part in the overall effort as well. Activities on prevention have since June 1992 being the object of 
the revised law on health insurance and the health sector. Apart from the provisions contained in 
this law, Luxembourg has not yet developed a separate and comprehensive programme on 
prevention. 
10. THE NETHERLANDS 
38 
Prevention policy in the Netherlands is based on a number of programmes. Disease prevention 
consists of national vaccination programmes, screening programmes, cervical and breast cancer 
screening programmes, and counselling services for mothers and young children. Systematic training 
on prevention is currently being introduced notably for general practitioners. Action on Health 
Promotion covers a wide range of activities such as national health education campaigns, school and 
workplace health education conferences, mental health education especially for groups at risk, such 
as the elderly, divorced couples, children, etc. Health education also focuses on alcohol, tobacco and 
drugs. Intersectoral actions are carried out in the work environment, notably for safety and health 
at work, etc. 
Preventive activities are carried out by national specialised institutions, municipal public health 
services, regional mental health services, regional addiction services and primary health care 
professionals. 
Disease prevention is financed by the insurance schemes. 
11. PORTUGAL 
The medium-term objective for the Portuguese strategy on prevention is to improve the standard of 
Public Health by means of campaigns against cancer, drugs, AIDS and by the prevention of stroke 
and cardio-vascular disease, the prevention of accidents in general, the prevention of suicide and by 
improving assistance to the elderly, to children and to young people. Moreover, the overall strategy 
seeks to improve conditions and the functioning of the health care system by increasing the number 
of beds for the chronic sick, by improving or replacing facilities providing health care, and by taking 
steps to rationalise existing human resources and promote a better distribution of medical health care 
personnel. The Ministry of Health is carrying out specific programmes on: control of diabetes 
mellitus and hypertension, vaccination, infant and juvenile health care, maternal health care, oral 
health, health at school, health education, a national cancer project, drug prevention, and AIDS. 
The prevention policy in Portugal is coordinated by the Ministry of Health and is laid down in the 
Portuguese National Health Service Law. The Ministry of Health is advised by the National Health 
Council which comprises representatives from all parties concerned with health protection. The 
National Health Council formulates recommendations on the overall health strategy and in this work 
it is assisted by a large number of consultative bodies. 
12. UNITED KINGDOM 
Prevention policy in UK is made up of four parts: 
- screening and immunisation programmes including breast and cervical cancer screening, and 
immunisation of all children for diphtheria, tetanus, whooping cough, polio, measles, mumps, 
rubella, BCG and HIB. 
- specific health iniatives, such as the "Health of the Nation" initiative for England launched in July 
1992 which identified five national priorities and set 27 targets. The priority areas concern coronary 
heart disease and stroke, cancers, mental illness, accidents, and HIV/AIDS and sexual health 
(including family planning). The implementation of this initiative is to be based on the commitment 
of all Government departments, on building health alliances at national and local level, on acting 
through appropriate settings, and on improved health monitoring and impact evaluation. 
- health promotion and education activities. For England, under the Health of the Nation strategy, 
priorities were established for activity by the Health Education Authority, both at national and local 
level, for health promotion as an explicit element in general practitioners' contracts and for 
widespread health promotion throughout the health service. Other preventive actions specifically 
concern smoking, alcohol, drug misuse, nutrition, family planning and dental health. 
- environmental health and public health actions include actions on the safety of medicines, 
consumer products and the environment, promotion of food hygiene at national and local level, and 
finally control and surveillance of communicable diseases. 
39 
ANNEX II 
COMMUNITY POLICIES AND INSTRUMENTS OF DIRECT RELEVANCE TO 
HEALTH PROTECTION 
1. OVERVIEW OF ACTIVITIES 
Health and the environment 
The close link between the environmental aspects of public health and the necessity of governmental 
intervention was well established throughout Europe by the end of the last century and by then 
international activity had already begun. The efforts of the European Community "to preserve, 
protect and improve the quality of the environment" and thus "to contribute towards protecting 
human health" are a continuation of this international activity made more influential and effective 
by EC powers to legislate and EC funds to assist implementation. The latest comprehensive 
expression of the Community's environmental activities is to be found in "Towards Sustainability", 
a European Community Programme of Policy and Action in relation to the Environment and 
Sustainable Development (COM(92) 23 final, Vol. II) adopted by the Council on 1 February 1993. 
This programme contains further proposals for improving the quality of water, air and soil, for 
controlling dangerous substances and industrial activities, and for monitoring radiation and 
controlling pollution and the disposal of waste. 
Health and safety at work 
The adoption of the Single European Act (1986) and inclusion of Article 118a gave a great boost 
to the Community's efforts to improve the health and safety of workers and reduce the risks from 
carcinogens and other dangerous substances and accidents at work. The Community's involvement 
in this area originated in the concern to improve working conditions in the Treaty establishing the 
Coal and Steel Community (April 1951), reinforced by the Social provisions (Title III) of the EEC 
Treaty and the health protection measures in the "Euratom" Treaty. Important measures were 
adopted from 1977 onwards, notably in 1980, but a significant step in Community involvement was 
taken in 1989 when a framework Directive (89/391/EEC) was adopted on the improvement of the 
safety and health of workers at work. A large number of subsequent Community measures have been 
adopted within this framework, establishing the Community as the driving force in occupational 
safety and health matters. Some of these measures link closely with the Community's Public Health 
measures in the field of toxicology and poison centres '. 
A healthy population requires healthy food. 
The need for food products to be safe, uncontaminated, and wholesome led to phytosanitary and 
veterinary controls, as well as to requirements for the composition of foodstuffs, the use of 
preservatives, additives, etc. and for informative labelling requirements. These matters are the subject 
of a number of internal market measures in the Community dating back as far as 1962. More 
recently (mid 1980s onwards) interest has been growing in the nutritional value of foodstuffs and 
additives for the promotion of health. Current public health concerns are to avoid foodstuffs which 
have an association with major diseases such as cancer and cardiovascular disease and to help people 
to choose sensibly what to eat through health education and by clear labelling on the components 
of food products. To this end, the Commission has instituted a major nutritional study under the 
"Europe against cancer"2 programme. 
Resolution of the Council and Ministers for Health of the Member States on improving the Prevention and 
Treatment of Acute Human Poisoning (90/C 329) of 3 December 1992 
European Prospective Investigation of Cancer, Nutrition and Health (EPIC) 1998/9 - 1998 
40 
Consumer protection 
The population also needs protection from other products and from the potentially harmful effects 
of some services. The products include not only medical products such as pharmaceuticals 3 and 
medical devices4 but also the whole range of potentially dangerous items available on the market. 
The Community's internal market measures to ensure a high level of health protection in these 
matters include "New approach" Directives relating to medical devices, personal protective 
equipment , machinery, toys, 5 etc, as well as directives and measures relating to consumer 
information general product safety and the monitoring of accident6 
Research and information technology 
Basic to developments in public health policy are the findings of research into the causes and 
transmission of diseases and ways to prevent them, including the use of modern techniques of 
information technology. The Community's successive medical and health research programmes have, 
since their start in 1978, contained an important element concerned with the prevention of disease. 
The current BIOMED programme contains similar provisions. Community information technology 
and telematics programmes and pilot schemes, often carried out in cooperation with WHO and the 
Council of Europe, have included elements concerned with the monitoring of congenital disease, the 
use of informatics in medicine (AIM), care systems (statistics, early warning, food safety and 
pharmacovigilance), and epidemiology. 
Social Security 
The coordination of social security systems gives insured people access under certain circumstances 
to health care in all other countries of the Community by means of regulation 1408/71/EEC, form 
Bill. 
The recognition of a right to benefit from systems for protection of human health regardless of 
personal resources is laid down in Council recommendation 92/442/EEC on the convergence of 
social protection objectives and policies. Access to systems for the protection of human health, 
regardless of an individual's resources, can be guaranteed either through a system of health 
insurance, which is open to persons of all income levels irrespective of their individual risk profile, 
or through the free provision of health care and prevention within a public health service. 
The health professions 
The health professions and staff of governmental and non-governmental organisations responsible 
for the provision of health services have a key role to play in the provision of advice and 
information for the promotion of public health and the prevention of disease. The Community's 
measures for the mutual recognition of professional qualifications between the Member States and 
for the development of cooperation and training in higher education and training institutions make 
an important contribution in this context. Elements of the Community's programmes to combat 
cancer and AIDS are designed to promote improved training for health staff involved in the fight 
against those diseases. 
3 Council Directives 65/65, 75/318 and subsequent legislation 
4 Council Directive 90/385/EEC of 20.6.1990 (OJ L 189 of 20.7.1990) and Council Directive 93/42/EEC 
of 14.6.1993 (OJ L 169 of 12.7.1993) 
5 Council Directive 88/378 of 3.5.88 (OJ LI 87 of 16.7.88) 
6 Council Directive 92/59 
41 
Disease prevention and health promotion 
The Community's public health activities since the mid-1980s have gone beyond control and 
protection from environmental and workplace health hazards to the encouragement and coordination 
of measures to combat major diseases and positively to promote health. 
The Community's programme to combat cancer (1987-1989) was the first major disease prevention 
programme. The "Europe against cancer" programme focused on actions in particular areas such as 
tobacco and alcohol consumption, dietary habits, exposure to carcinogens and to the sun. It 
encouraged appropriate screening programmes and information on early detection and promoted a 
ten-point European Code against Cancer for the general public. The Community, using internal 
market provisions, adopted legislative measures on tobacco to improve and control the labelling of 
tobacco products and the tar content of cigarettes. A recommendation on smoking in public places 
was adopted and a proposal for a directive to ban the advertising of tobacco products is currently 
under consideration. A further programme to combat cancer was adopted to continue the activity 
from 1990 to 1994, which, mid-way through its implementation, has demonstrated its value and 
effectiveness, its power in agenda setting, and its impact, through its partners at all levels, on 
raising awareness. 
Other major public health programmes soon followed as political pressure and health developments 
demanded Community action. The "Europe against AIDS" programme (1991-1993) has ten main 
action areas. As with cancer, some actions concerned the raising of public awareness, improved 
health education and cooperation with the Commumty's research programme. Other new elements 
were also introduced to suit the particular nature of the disease, including social support and 
counselling, estimates of the costs of managing HIV infection and efforts to combat discrimination 
against HIV-infected persons. Following the evaluation by the Council of the action under the 
programme, and in anticipation of the coming into force of the Treaty on European Union, the 
Council and the Ministers for Health have sought to prolong the programme to the end of 1994. 
The European Plan to combat the abuse of drugs has a particular element concerned with public 
health actions to reduce the demand for drugs. Information exchanges, the raising of public 
awareness, and assistance for pilot projects on prevention are features of the plan. A European Drug 
Prevention week is an important means of fostering cooperation and raising awareness. 
For the public to know about and respond to such guidelines as the European Code against Cancer, 
a sustained programme of health promotion and education and the provision of relevant information 
is necessary. WHO's programme "Health for All by the Year 2000" stressed this approach and the 
Community's initiatives on health education, instituted by both the Education and the Health 
Ministers, are concerned with the subject. Campaigns to persuade people to change their behaviour 
have also been launched in the context of the Community's programmes to combat cancer and AIDS 
and actions on drug abuse. 
Other aspects 
There are, of course, other aspects of the Community's public health activities. Actions to promote 
the attainment of self-sufficiency in human blood or plasma derived from voluntary non-remunerated 
donations and to develop the production of blood products coming from these donations are a good 
example. There have also been actions in the field of toxicology for health protection, on improving 
the prevention and treatment of acute human poisoning, in the development of the European 
Emergency Health Card and in a number of other areas, not only in the sphere of public health, but 
also as part of other Community policies. 
42 
2. LIST OF COMMUNITY INSTRUMENTS OF DIRECT RELEVANCE TO HEALTH PROTECTION 
• EEC Treaty: 
(1951-1957): implicit recognition of public health concepts by reference to "accelerated raising 
of the standard of living " - many articles indirectly relevant to health protection 
• Euratom Treaty: 
(1957): provides for : 
basic safety standards to be laid down within the Community for the protection 
of the health of workers and the general public against the dangers from ionizing 
radiations (Ch. Ill) 
safeguard inspections and training of inspectors (Ch. VII) 
conclusion of agreements or conventions with international organisations, third 
countries (Ch. X) 
• With the adoption of the Single Act: 
(1986): a specific legal basis concerning health, safety, environmental protection and consumer 
protection was established: Article 100a. 3; Article 118a (protection of workers health and safety) 
; environment (Articles 130r, 130s, 130t) 
• Health & safety at work : 
(1977-78): adoption of the first Council Directive concerning safety signs and the Directive 
concerning vinylchloride monomer (based on Article 100 of the EEC Treaty). 
1980: Council Directive concerning the protection of workers against chemical, 
physical and biological agents (Article 100) 
1989: adoption of the framework directive 89/391/EEC concerning main aspects of 
health and safety at work (Article 118a), and twelve other directives on 
particular aspects of occupational safety and health 
• Environment: 
EEC Treaty : Articles lOOr, 100s, lÔOt 
1) Dangerous substances, industrial risk, biotechnology. Examples include: 
1967: Council Directive 67/548/EEC relating to classification, packaging and 
labelling of dangerous products. (OJ LI96, 16.8.1967 p.l) 
1976: Council Directive relating to restrictions on the marketing and the use of 
certain dangerous substances and preparations (OJ L262 27.9.1976, p.201) 
1982: Council Directive on the major accident hazards of certain industrial 
activities (OJ L230, 5.8.1982, p.l) 
1993: Council Directive on principles for assessment of risks to man and the 
environment of substances 
2) Air. Example include : 
1970: Council Directive concerning air pollution by emissions from motor vehicles 
(OJL76, 6.4.1970, p.l) 
43 
1982: Council Directive on a limit value for lead in the air (OJ L378, 31.12.1982, 
p.15) 
1985: Council Directive on air quality standards for nitrogen dioxide (OJ L87, 
27.3.1985, p.l) 
3) Directives on waste (OJ L194, 25.7.1975, P.39) waste water treatment (OJ L135, 
30.5.1991, p.40) waste prevention of air pollution from waste incineration plants. (OJ 
L163, 14.6.1989, p.32; OJ L203, 15.7.1989, p.50) 
4) Noise (motor vehicles, aircraft, construction plants, household appliances, etc.) (OJ 
L42, 23.2.1970, p. 16) 
5) Water (drinking water quality, bathing water) (OJ L347, 17.12.1973, p.l). 
• Consumer protection 
Foodstuffs 
Since 1962 Council Directives concerning additives used in foodstuffs intended for human 
consumption have been adopted (based on Article 100 of the EEC Treaty). In 1969 a 
Standing Committee for Foodstuffs was set up. The Scientific Committee for Food which 
sets up list of additives and the conditions for their use was set up in 1974. 
1985: Council Directive concerning certain substances having hormonal action. 
1989: Council Directive on the Official control of foodstuffs and Council Directive on the 
approximation of laws of the Member States relating to foodstuffs for particular 
nutritional uses (based on Article 100a.3 of EEC Treaty). 
1990: Council Directive related to quick-frozen foodstuffs for human consumption 
Council Directive on nutrition labelling for foodstuffs. 
Council Directive relating to plastic materials intended to come into contact with 
foodstuffs. 
Other: 
1989: Council Decision on a Community system for the rapid exchange of information and 
the dangers arising from the use of consumer products (Article 235). 
1988: Council Directive concerning safety of toys 
1991: Council Directive on control and acquisition of weapons 
1992: Council Directive on general product safety. 
• Pharmaceuticals 
In 1965 the Council adopted the first directive on the approximation of the provisions 
relating to proprietary medicinal products, based on Article 100 of the EEC Treaty. 
1975: Setting up of a pharmaceutical committee: the Committee for Proprietary Medicinal 
Products ; Council Directive relating to standards and protocols in respect of the 
testing of proprietary medicinal products. 
1987: Council Directive concerning the approximation of national measures relating to the 
placing on the market of high-technology medicinal products, and Council Directive 
44 
concerning tests relating to the placing on the market of proprietary medicinal 
products. 
1989: Council Directive 89/342/EEC on vaccines, 89/343/EEC on radiopharmaceuticals, 
89/381/EEC on blood derivatives, and 89/105/EEC on the transparency of the pricing 
and reimbursement of medicinal products for human use (Article 100a). 
1991 : Commission Directives on pharmaceutical good manufacturing practice (91 /3 56/EEC) 
and on testing requirements for medicinal products (91/507/EEC). 
1992: Council directives on wholesale distribution, legal classification for the supply, 
labelling and advertising of medicinal products for human use (Article 100a). 
1993: Council Regulation EEC n* 2309/93 (Article 235 if the EEC Treaty) and Council 
Directives 93/39/EEC and 93/40/EEC (Article 100a) creating an European Medicines 
Evaluation Agency and establishing new Community procedures for the registration 
of medical products for human and veterinary use. 
• Free circulation of persons 
1964: Council Directive 64/221/EEC on the coordination of special measures for foreign 
nationals on grounds of public order, public security or public health, concerning 
their movement and residence (Article 56, para. 2, of the EEC Treaty). 
• Medical and para-medical activities 
1975: - Setting up of a Committee of Senior Officials on Public Health concerned with 
the : 
- Directive on the mutual recognition of diplomas of doctors (articles 49, 57 and 66 
of the EEC Treaty) 
- Directive on the coordination of provisions in respect of activities of doctors 
(Articles 49, 57, 66 and 235 of EEC Treaty) 
Followed by the: 
- Council Directive concerning the mutual recognition of diplomas of nurses 
(1977); of dentists (1978); of midwives (1980); pharmacists (1985) and of 
general practitioners (1986). 
• Medical devices 
The Council has adopted several directives concerning protection of health and safety 
of persons with regard to placing medical devices on the market: 
- Directive 84/539/EEC on electro-medical equipment used in human or in 
veterinary medicine; 
- Directive 90/385/EEC on active implantable devices; 
- Directive 93/42/EEC on medical devices. 
45 
ANNEX HI 
HEALTH PROTECTION REQUIREMENTS AS A CONSTITUENT PART OF OTHER 
COMMUNITY POLICIES 
Cooperation in the fields of law and internal affairs: 
Control of persons at external frontiers, immigration, drugs, and European 
Monitoring Centre for Drugs and Drugs Addiction 
Citizens' rights: 
Accession to the European Convention on Human Rights. 
Protection of personal data. 
External affairs: 
PHARE and TACIS; UN drugs. 
Relations with international organisations: Council of Europe, WHO, FAO, 
OECD, IOM, UNESCO, UNDCP, IAEA, UN. 
Acceptance of the European Pharmacopoeia 
Cooperation with third countries: EFT A, CEEC, Mediterranean countries, Latin 
America, North America etc.. 
Negotiations with ASEAN on the illicit manufacture of drugs and psychotropic 
drugs. 
Monitoring of intra-Community and international traffic in drugs and psychotropic 
drugs. 
k Internal market: 
Quality, safety and hygiene of food products, warning system, labelling, additives, 
colouring agents, contaminants, interaction between diet and health, packaging. 
Medical equipment; standardisation, e.g. in vitro diagnosis; pharmaceutical 
products; cosmetic products; drugs and precursors. 
substances and dangerous preparations, classification and labelling; fertilizers, 
biocides. 
Regulation of qualifications of (health) personnel. 
¥ Competition: 
Price of medicinal products; social security systems. 
* Social affairs: 
Women and health, social protection, disabled persons, the elderly, migrants, 
poverty, health protection of workers, European Social Fund. 
* Education and Training: 
ERASMUS, activities intended for young people and health professionals. 
* Agriculture: 
Quality and health of plants, animals and specialised crop species (fruits and 
46 
vegetables, wine, alcohol, tobacco, etc.); hygiene related to fish, shellfish, milk, 
dairy products. 
Promotion of consumption of olive oil, dairy products, fruits and vegetables. 
Veterinary and phytosanitary controls within and outside the Community. 
Fisheries 
Quality of products from fishing and aquaculture; 
Promotion of consumption of products from fishing and aquaculture; 
Promotion of sanitary conditions of production, consumption and 
commercialisation of products from fishing and aquaculture. 
Transport: 
Transport safety; prevention of accidents, in particular road accidents associated 
with alcohol, accident database. 
Development: 
Cooperation actions concerning health systems reform, and programmes and 
projects of support to the development of health. 
Campaign against AIDS. 
R&D programme in the field of science and technology for development, sub-
programme on medicine, health and nutrition in tropical and sub-tropical areas. 
Culture. Communication and Information: 
People's Europe: activities aimed at young people, e.g. drugs, AIDS; sport. 
Environment: 
Nuclear safety and health protection (EURATOM); protection against other 
physical agents: noise, low frequency electromagnetic waves. 
Control of dangerous chemical substances and preparations; dangers associated 
with biotechnology and genetically modified organisms; 
Control of emissions from industrial installations; waste management. 
Quality of the air, soil, water, drinking water. 
Civil protection. 
Research: 
Community Reference Bureau 
Nuclear safety; radiation biological and health effects; assessment of risks of 
natural and medical radiation. 
Biotechnology : neurosciences 
BIOMED 1: human genome analysis; biomedical ethics; research on health 
services and technologies and diseases associated with lifestyle: AIDS, cancer, 
drugs, ageing, quality control. 4th RTD programme: preventive and 
epidemiological research on diseases with major socio-economic impact and 
genetic diseases. Research on health systems, on evaluation of needs, and on 
education and information on health matters. European Brain Research. 
47 
Telecommunications and telematics programme : 
Telematics programme for health care (AIM) improved quality assurance and 
effectiveness of therapeutic and social measures and primary health services, 
resource management medical images, health records, rehabilitation patient data 
cards etc... via results of several specific projects, concerted action and 
accompanying measures: RACE, ESPRIT, IMPACT, TIDE. 
Telematics programme for administration (ENS) CARE project: rapid, efficient 
access to health statistics; pharmacovigilance, etc. 
Legal protection of data(Council of Europe recommendations) 
Indirect taxation: 
Distilled and fermented beverages, processed tobacco. 
Tourism 
Consumer protection: 
General safety of products and services and liability; EHLASS project; system for 
the rapid exchange of information; consumer information and education. 
ECHO: 
Emergency humanitarian aid for non-member countriess. 
Social and health statistics 
48 
Annex IV 
IDENTIFICATION OF "MAJOR SCOURGES" IN THE EUROPEAN COMMUNITY 
Disease / 
Health Problem 
CANCER 
Cancer of colon 
Lung cancer 
Digestive organs 
Breast cancer 
Prostate cancer 
DISEASES OF THE CIRCULATORY SYSTEM 
Hypertensive disease 
Acute myocardial infarction 
cerebrovascular 
ischaemic heart disease 
RESPIRATORY DISEASES 
Bronchitis, emphysema , asthma 
Congenital abnormatlities 
Perinatal conditions 
ACCIDENTS (including poisoning) 
Motor vehicle accidents 
Drug and alcohol abuse 
Musculo-skeletal problems Standardised death rates per 
100,000 or incidences per 
100,000 (estimates) 
337 
29 
42 
62 
33 
19 
338 
16 
90 
90 
137 
17 
5 
5 
51 
15 Costs for Health Services 
(and other costs eg. 
absenteeism) 
*** 
**** 
*** 
*** 
*** 
**** 
*** 
**** Practical possibilities for 
prevention 
*** 
*** 
*** 
**** 
**** 
**** 
**** 
*** Community Added Value 
(opportunities for 
intervention) 
***• 
**** 
*** 
*** 
*** 
**** 
**** 
*** "Major Scourges" 
(major health problems) 
**** 
#*** 
*** 
* 
* 
**** 
*•** 
*** Previous Community public 
health action 
• *#* 
** 
** 
** 
** 
** 
*** 
** 
**** = HIGH *** = MEDIUM ** = LOW * = NONE 
49 
Disease / 
Health Problem 
Visual problems 
Auditory problems 
Mental disorders 
suicides 
Nutrition related disorders, including diabetes, dental caries 
AIDS 
OTHER COMMUNICABLES DISEASES, EG. 
sexually transmitted diseases and tuberculosis 
CHILDHOOD INFECTIONS, e.g. 
Measles 
rubella 
other childhood infections 
RARE DISEASES, e.g. 
Thalassaemia , sickle-cell anemia, rickets 
FOOD BORNE DISEASES 
, e.g. salmonella poisoning Standardised death rates per 
100,000 or incidence per 
100,000 estimates 
13 
2.41 (incidence) 
51 (incidence) 
26 (incidence) Costs for Health Services 
(and other costs e.g. 
absenteeism) 
** 
* 
**** 
*** 
*** 
*** 
** 
* 
** Practical possibilities for 
prevention 
** 
** 
** 
*** 
**** 
**** 
.... 
*** 
**** Community Added Value 
(opportunities for 
intervention) 
* 
* 
* 
*** 
**** 
**** 
**** 
*** 
**** "Major Scourges" 
(major health problems) 
* 
* 
*** 
** 
*** 
*** 
* 
** 
*** Previous Community public 
health action 
* 
* 
* 
*** 
*** 
*** 
* 
* 
* 
HIGH *** = MEDIUM ** = LOW * = NONE 
50 
ANNEX V 
STATISTICAL DATA 
Total and public expenditure on health care in relation to national 
expenditure in the Community, 1970, 1980 and 1991 
1Q % national expenditure (GDP less exports plus imports) 
Total expenditure H3 Public expenditure 
8 LI 10 
GR P E L UK 
Public «Denature a au GR. L P 1990 OK IRL I NL O F 
FIGURE 1 
51 
Temporal distribution of causes of death EUR 12 
52 
Caoscs of deaths by age grotfp - EUR 12 - 1989 (1) 
Tumours 
l—t 5-1A 15-24 25-54 35-44 45-5* S5-<H Û5-74 *-75 
A^e 
Diseases of the circulatory system 
1-4 5-14 15-24 2S-34r SS—44.45-64. 55-«4 R5-74 VT5 
Age 
Other causes (3) 
(1) Belgium 1986; Spain 1987; Italy 1988. 
(2) tn this year group nearly all accidents are traffic related. 
(3) Infecnous and parasitic diseases, diseases of the digestive system, of the gcoito-uninary 
system, of the nervous system, of the blood, skin etc. 
FIGURE 4 
54 
TABLE S 
LEADING CAUSES OF DEATH BY AGE AND SEX 
IN THE EUROPEAN COMMUNITY 
Age 
under 1 years 
1 - 4 years 
5-9 years 
10 - 14 years 
20 - 24 years 
28 - 29 years 
30 - 34 years 
35 - 39 years 
40 - 44 years 
45 - 49 years 
50 - 54 years 
55 - 59 years 
60 - 64 years 
65 - 69 years 
70-74 years 
74 - 79 years 
80 - 84 years 
over 85 years Male 
Hypoxia, birth asphyxia 
& other respiratory conditions 
Motor vehicle accident 
Motor vehicle accidents 
Motor vehicle accidents 
Motor vehicle accidents 
Motor vehicle accidents 
Motor vehicle accidents 
Suicide 
Acute myocardial infarction 
Acute myocardial infarction 
Acute myocardial infarction 
Acute myocardial infarction 
Acute myocardial infarction 
Acute myocardial infarction 
Acute myocardial infarction 
Acute myocardial infarction 
Acute myocardial infarction 
Diseases of pulmonary circ. & 
other cardiopathies Female 
Hypoxia, birth asphyxia 
& other respiratory conditions 
Congenital anomalies of heart 
& circulatory system 
Motor vehicle accidents 
Motor vehicle accidents 
Motor vehicle accidents 
Motor vehicle accidents 
Suicide 
Breast cancer 
Breast cancer 
Breast cancer 
Breast cancer 
Breast cancer 
Breast cancer 
Acute myocardial infarction 
Acute myocardial infarction 
Acute myocardial infarction 
Acute cerebrovasc. disease 
Diseases of pulmonary circ. & 
other cardiopathies 
Source : World Health Organisation 
55 
ISSN 0254-1475 
COM(93) 559 final 
DOCUMENTS 
EN 05 
Catalogue number : CB-CO-93-600-EN-C 
ISBN 92-77-61143-X 
Office for Official Publications of the European Communities 
I ,-2985 Luxe mb ours