EUROOPAN YHTEISÖJEN KOMISSIO 
Bryssel, 19.07.1995 
KOM(95) 357 lopull. 
KOMISSION KERTOMUS 
NEUVOSTOLLE, EUROOPAN PARLAMENTILLE, 
TALOUS- JA SOSIAALIKOMITEALLE 
JA ALUEIDEN KOMITEALLE 
terveydentilasta Euroopan yhteisössä 

CONTENTS 
Preamble i 
Executive summan- ii-iii 
I. Chapter 1 - Introduction 1 
1.1 Why a health report for the Community? 1 
1.2 Describing health and its determinants 2 
1.3 Structure of this report 3 
II. Chapter 2 - The population's health 5 
2.1 Population trends 5 
2.2 Life expectancy 7 
2.3 Differences persist 8 
III. Chapter 3 - Patterns of health, disease and disability 10 
3.1 Children 10 
3.2 Young people 12 
3.3 Adults 13 
3.4 Older people - 19 
IV. Chapter 4 - The determinants of health 21 
4.1 Health-related behaviour 21 
4.2 The environment and health 25 
4.3 Social concerns 27 
4.4 Health services 28 
V. Chapter 5 - Towards a healthier Europe 33 
Annexes 
Annex 1. Notes and glossary 35 
Annex 2. List of figures 37 
Annex 3. Tables of causes of death, EC, 1991 65 
Annex 4. Bibliography 73 
4* 
PREAMBLE 
The Treaty of European Union created new responsibilities in public health for the European 
Community. Article 129 of the Treaty lays down a general objective for the Community to 
contribute towards ensuring a high level of human health protection and makes provisions for 
the kinds of Communitv action that should be undertaken to meet this objective. 
The Commission Communication on the framework for action in the field of public health 
(COM (93) 559 final of 24 November 1993) sets out how the Commission intends to 
implement this new Community competence. Among other proposals made, it envisaged that 
a health status report should be prepared for the European Community (EC) on a regular basis. 
This is the first such report. It provides an overview of health status in the EC in 1994, 
including a description of the main demographic trends and patterns of mortality and 
morbidity, and a discussion of the major determinants of health. It also gives information 
about certain key Community actions and programmes with implications for health. 
This report is based upon work carried out by the Regional Office for Europe of the World 
Health Organization using information in their Health For All database and other readily 
available data. The Commission provided them with support for this task. Since the requisite 
work was carried out prior to the accession of the three new Members States it has not been 
possible to include information on them in the report. 
Future reports will in principle be produced annually. Their subject-matter will reflect 
important developments in health status within the Community and also take account of the 
concerns of the Community population. It is intended that individual reports should focus on 
specific issues, but general overviews of the evolving state of health will be provided at 
appropriate intervals. 
Ah 
Yhteenveto 
Tässä kertomuksessa kuvataan terveydentilaa Euroopan yhteisössä vuonna 1994. 
Tässä kertomuksessa kuvataan vuonna 1994 käytettävissä olleiden tietojen perusteella 
Euroopan yhteisön (EY) 12 jäsenvaltion asukkaiden terveydentilaa, heitä koskevia 
terveystekijöitä ja toimintamahdollisuuksia kansanterveysalalla yhteisössä. Kertomus sisältää 
selonteon terveyden kehityssuunnasta ja voi toimia sekä perustana tulevia toimia arvioitaessa 
että tukena yhteisön kansanterveyspolitiikan kehitykselle. Yhteisön nykyisiä toimintaohjelmia 
kuvataan silloin, kun se on aiheellista. 
Väestön terveys 
* Vähemmän lapsia, enemmän vanhuksia 
Yhteisön väkiluku on hieman alle 350 miljoonaa ihmistä. Lasten osuus väestöstä on 
vähentynyt 1970-luvulla alkaen alentuneen syntyvyyden seurauksena samalla kun vanhusten 
osuus ja määrä ovat kasvaneet. Vuonna 1992 nettomuutto EY-maihin oli noin miljoona 
ihmistä. 
* Ihmiset elävät kauemmin 
Terveydentila yhteisössä on parantumassa: kaikissa maissa lapset ovat yhä terveempiä ja 
aikuiset elävät yhä pidempään. Keskimääräinen elinikä, 76,5 vuotta vuonna 1991, on 
korkeampi kuin Yhdysvalloissa (75,5 vuotta vuonna 1990), joskin se on alhaisempi kuin 
Japanissa (79,6 vuotta vuonna 1992). Miesten odotettavissa oleva elinikä on keskimäärin 
seitsemän vuotta alhaisempi kuin naisten, ja viidesosa kaikista kuolemantapauksista on 
ennenaikaisia (toisin sanoen ne tapahtuvat ennen 65 vuoden ikää). 
* Erot säilyvät 
Terveydentilassa esiintyy vaihtelua sekä maiden sisällä että välillä. Kuolleisuus on korkeampaa 
alempaan sosioekonomiseen luokkaan kuuluvien ihmisten keskuudessa. Myös alueellisia ja 
paikallisia eroja esiintyy. 
Terveyttä, sairautta ja vammaisuutta koskevat suuntaukset 
* Lapset ovat terveempiä 
Sylivauvojen kuolleisuus on vähentynyt koko tämän vuosisadan ajan. Synnynnäiset anomaliat 
ovat edelleen sylivauvojen kuolemien ja vammaisuuksien suurimpia syitä. Tapaturmat ja 
syövät ovat pääasialliset syyt 1-14 -vuotiaiden lasten kuolemiin. Hammasterveydenhuolto 
parantuu ja tarttuvat lastentaudit vähentyvät rokottamisen ansiosta. 
M 
* Nuoret seuraavat aikuisten käyttäytymismalleja 
Tapaturmat, erityisesti liikennetapaturmat, ovat pääasiallinen kuolemansyy 15-34 -vuotiaiden 
keskuudessa. Nuorten terveyskäyttäytyminen heijastaa aikuisten käyttäytymistä. Yksi kahdesta 
nyt tupakoinnin aloittavasta teini-ikäisestä kuolee tulevaisuudessa tupakoinnin seurauksena, jos 
hän jatkaa tupakointia keskeyttämättä. 
* Ennenaikainen kuolema on tavanomaista keski-iässä 
Suurimmat syyt aikuisten ennenaikaiseen kuolemaan ovat sydäntauti, halvauskohtaus, syöpä 
ja tapaturmat. Kuolleisuus sydäntauteihin ja halvauskohtauksiin vähenee, mutta useimmissa 
maissa kuolleisuus keuhkosyöpään kasvaa. Monet tekijät - usein eri tekijät yhdessä -
myötävaikuttavat näiden tautien ja vammojen syntyyn. Tupakoinnilla on suuri vaikutus 
erityisesti sydäntautien, keuhkosyövän ja muiden hengitystietautien esiintymiseen. 
* Krooniset taudit ja vammaisuus ovat hallitsevia vanhusten keskuudessa 
Vanhusten keskimääräisen eliniän noustessa on kiinnitettävä erityistä huomiota tämän 
ikäryhmän vammoihin ja kroonisiin sairauksiin. Näihin sisältyvät fyysiset vammat kuten 
nivelsairaudet, aistivammat, mukaanlukien huono kuulo ja henkinen vajaamielisyys kuten 
dementia. 
Terveystekijät 
* Käyttäytyminen vaikuttaa terveyteen 
Viidellä terveyteen liittyvällä eri käyttäytymismallilla - tupakoimisella, alkoholin väärin­
käytöllä, huumeiden väärinkäytöllä, ruokavaliolla ja liikunnalla - on tärkeä vaikutus terveyteen 
ja sairauteen. On arvioitu, että tupakanpoltto saa vuosittain aikaan puoli miljoonaa 
kuolemantapausta yhteisössä. Naisten tupakanpoltto on lisääntynyt, vaikka miesten tupakoinnin 
osalta suuntaus on laskemassa. Alkoholin väärinkäyttö liittyy erityisesti sosiaalisiin ongelmiin, 
väkivaltaan ja itsemurhiin. Merkittävin suuntaus on ollut kulutuskäyttäytymisen muutos 
perinteisissä viini- ja olutmaissa. Huumeiden väärinkäyttö lisääntyy, ja huumausaineiden 
yliannostuksesta johtuva kuolleisuus lisääntyy tietyissä maissa. Huomattavat pohjoisen ja 
etelän väliset ruokavalioerot vaikuttavat sairauseroihin, ja muutamissa EY-maissa esiintyy 
paljon sairaalloista lihavuutta. Liikunta edesauttaa hyvää terveyttä, mutta tieto 
liikuntaharrastuksen määristä puuttuu. 
* Ympäristö vaikuttaa terveyteen 
Kaikissa EY-maissa esiintyy puutteellisuuksia asuntojen ja saniteettitilojen suhteen, ja melkein 
kahden ja puolen miljoonan ihmisen arvioidaan olevan kodittomia tai elävän tilapäisessä 
majoituksessa. Liikenteellä on merkittävä vaikutus terveyteen. Huono ilman laatu vaikuttaa 
koko väestöön, ja erityisesti herkkiin ryhmiin kuten astmaa ja hengitysvaikeuksia poteviin. 
* Sosiaalinen asema vaikuttaa terveyteen 
Työttömyys ja sosiaaliset erot ovat kaksi lisätekijää, jotka vaikuttavat terveyteen. Työttömyys 
on lisääntynyt 1990-luvulla, ja nuorten työttömyysmäärä on erityisen korkea EY:n eteläisissä 
44. 
jäsenvaltioissa. Sosiaalisia eroja esiintyy yhä kaikissa EY-maissa, mutta ne näyttävät olevan 
pienempiä joissakin pohjoisissa maissa. 
* Terveydenhuolto yksinään ei ole vastaus 
Terveydenhuolto huolehtii sekä sairaiden ihmisten hoidosta että yksilöllisen terveyden 
edistämisestä. Tärkeimpien terveysongelmien ennaltaehkäiseminen riippuu kuitenkin myös 
väestön tasolla toteutuista käyttäytymistä koskevista, taloudellisista ja sosiaalisista toimista. 
Kohti terveellisempää Eurooppaa 
Herää kysymys miten paljon keskimääräistä odotettavissa olevaa elinikää voidaan vielä 
pidentää. Pääasiallinen mahdollisuus pidentää keski-ikää lähitulevaisuudessa on vähentää 
nuorten ja keski-ikäisten ihmisten kuolleisuutta syöpään, sydäntauteihin ja ulkopuolisten 
tekijöiden aiheuttamiin vammoihin. 
f 
Chapter 1 
Introduction 
1.1 Why a health report for the Community? 
In the European Community (EC), common approaches to existing problems are increasingly being 
implemented not only in the area of economic integration, but also in other areas such as migration, 
the environment, education and research. 
Health is no exception to this. Not only are health problems tending to become more and more 
international in character, but the major problems appear to be growing more similar across countries 
as well. Moreover, as international cooperation on health has developed, attempts are being made to 
find common solutions and to increase the exchange of experience and expertise. As a result of such 
efforts, interest in other countries' problems and policies has increased and international information 
on health has become increasingly important. 
At the same time, people in the European Community are becoming healthier than ever before. 
Improved housing, water and sanitation, better hygiene, improved nutrition and specific medicines, such 
as vaccines and antibiotics have together contributed to a major improvement in health. One measure 
of the improving health in the Community over the past four decades is the steady rise in life 
expectancy at birth for all EC countries (Fig. l.l). Fig. l.l also shows another striking example of 
improvement in the form of the increasing height of the population, in this case young men in the 
Netherlands - amongst the tallest people in the Community. 
Yet there are important health problems to be overcome. In this century, Europe has changed 
rapidly from a mainly rural society into an affluent industrial society of people living in cities. Social 
changes include the decreasing size of families and households and increasing numbers of older people 
and people living alone. The major diseases of adult life are heart disease, stroke, cancers, accidents 
and mental illness, while AIDS is a new and growing problem. 
A highly developed and specialized health care system will not be able to solve these emerging 
health problems alone. Neither will increased resources channelled solely into health services and health 
technologies be sufficient by themselves to significantly improve the overall state of health. To reduce 
deaths and disability, the health services and other sectors with activities affecting health need to take 
more preventive action directed both at individuals and, through public health measures, at the whole 
population. 
A coordinated effort by the Member States of the European Community can add value to such 
action. In the 1980s. Member States steadily increased their cooperation in the public health field to 
cover a wide range of health problems. Common action has been undertaken in important areas such 
as health and safety at work, cancer prevention, alcohol and drug abuse, health education and AIDS. 
Moreover, the Community has substantially increased resources for biomedical and health research 
programmes. 
*i 
With the Treaty on European Union. Community action in public health has been given a specific 
legal basis. Article 129 of the EC treaty requires that "the Community shall contribute towards 
ensuring a high level of human health protection" and commits the European Community to contribu­
ting to disease prevention, in all its aspects, through Community action. The Commission, the European 
Parliament and the Council of Ministers have all contributed to the earning forward of these new 
responsibilities and to the practical implementation of the obligations of the Treaty (1.2J). 
Both the Commission (It and the European Parliament (2) recommended a regular report on the 
state of health in the European Community, with the former recommending that it should be based 
mainly on reports by Member States. This is the first report:1 it provides an overview of the health 
status of people in the Community and the determinants of health, and it indicates the broad areas 
where further health improvements are possible. 
1.2 Describing health and its determinants 
Health and disease can be described in various ways. Surveys of the general population in six EC 
countries reveal that most people rate their own health as good (Fig. 1.2.1). However the variations 
shown between countries need to be interpreted cautiously since they may reflect differences in the 
questions being used, as well as different levels of contentment of people in these societies. A second 
source of information comes from health services, which record people who have perceived a health 
problem and sought care. The majority of illness episodes are treated at the primary care level, but 
some need more specialized care in hospital. An important source of incidence data for the Community 
is disease registers, such as those for cancer, congenital anomalies and AIDS. A third source of 
information is death records. Causes of deaths are certified by doctors according to an internationally 
agreed coding system and are relatively the most reliable data for international comparisons on health 
status. 
Except for hereditary diseases and the process of aging, ill health results from the interplay between 
our genetic constitution, our physical environment, our society and our personal behaviour. Some types 
of ill health have apparently clear causes that are well known: for example, a fall may cause a broken 
arm and cigarette smoking may cause lung cancer. 
However, more usually several factors are at work together - for example, a fall may cause a 
fracture when a person has poor nutrition and weakened bones, and smoking contributes, with dietary 
factors and lack of exercise, to causing heart disease. 
Two sorts of health risk are considered in this report - risk for the individual and risk for the 
population. Individual risk includes the person's inherited constitution, personal behaviour and the 
environment to which the individual is exposed. Such risks are well known to insurers, who give 
discounts on life insurance to people who do not smoke and make higher charges for motor insurance 
to young drivers. However, population risk depends on the number of people exposed and the level 
of exposure with even small changes affecting a large number of people. This is the rationale for 
population-level action for example in areas such as nutrition and smoking. 
Progress in public health is reported by individual European countries to the World Health Organization 
in accordance with the European Regional Health for All Strategy. Since 1984. this has provided a 
framework for public health action, with 38 specific targets or health status goals. Because of this long­
standing work, and the information provided by all EC countries, the Commission requested the 
European Regional Office of WHO to produce this report. 
1.2.1 Information sources" 
This report is based on information from a wide range of existing sources. These include data held by 
the Statistical Office of the European Communities (EUROSTAT) and the Organisation for Economic 
Co-operation and Development (OECD) and by the European Regional Office of the World Health 
Organization (WHO) in its health for all database. Moreover, it includes information provided to WHO 
by Member States as part of their national health for all monitoring reports, information published by 
national governments and local reports, and published scientific work. It also includes data collected 
by disease-specific centres, such as the International Agency for Research on Cancer (IARC) in Lyon 
and the European Centre for the Epidemiological Monitoring of AIDS in Paris, and networks such as 
the European Registration of Congenital Anomalies and Twins (EUROCAT). 
The report uses this information to describe and compare trends over time, and differences between 
countries. The information always relates to the 12 EC countries which were Member States in 1994. 
irrespective of the year to which the data refer. Patterns of deaths, disease or injuries are mainly 
presented as rates - the number of events for a specific population size. These rates are usually 
"standardized" by age. that is adjusted to take account of age structures of the different populations. 
Sometimes, however, absolute numbers are used rather than rates. 
The process of using the existing data to describe current levels and patterns of health and disease 
and their determinants, as precisely as possible, has revealed gaps in the information currently available 
in the Community. This should help to point out areas where new data should be collected or the 
existing data need to be improved. 
In some cases it has been necessary to use data which do not cover the entire Community. In such 
cases, the most representative examples have been chosen, in order not to detract from the general 
conclusions of the report. 
Data for Germany up to 1990 usually refer to the Federal Republic of Germany within its territorial 
boundaries up to 3 October 1990. and those after 1990 to the Federal Republic including the acceding 
territory, unless otherwise noted. 
Full sources of all figures, together with notes, definitions, a glossary of terms and a bibliography, are 
presented in the annexes. 
1.3 Structure of this report 
The purpose of this report is to provide a picture of health in the European Community. The report 
does not aim to cover all diseases or health problems but deals only with the problems which have 
most impact on health status and those which are most likely to be influenced by Community policies. 
Chapter two starts with information on the size of the Community's population, trends in births and 
migration, and the changing proportions of young and older people. Trends in health status, indicated 
by life expectancy, are compared between countries. The final section points to the variations in health 
that exist, by sex. social group and geography. 
Chapter three outlines the major patterns of health, disease and disability at different stages of life. 
Death rates are used to describe the major life-threatening diseases. 
Chapter four describes the broader behavioural, environmental and social determinants of health, 
and the relation of health services to health protection. 
Chapter five highlights the main potential for increases in life expectancy in the future. 
References 
1. Commission Communication on the framework/or action in the field of public health, 24 November 
1993. (COM (93) 559 final). 
2. Resolution of the European Parliament, 19 November 1993, (OJ C 329 of 5.12.1993). 
3. Resolution of the Council of Ministers, 2 June 1994, (OJC 165/1 of 17.6.1994). 
Chapter 2 
The population's health 
There are just under 350 million people in the European Community. Member States range in size 
from Luxembourg (395 000 people) to Germany (81 million people) (Fig. 2.0.1). The population is 
growing slowly, depending on the balance of births and deaths, and migration. Life expectancy is in­
creasing, although not as fast as in some other countries. Cross-sectional and time-series data on 
variations are not complete: for mortality these are only generally available by age. cause of death, sex 
and geography: social group data is available for only a few countries. 
2.1 Population trends: 
fewer children, more older people 
The total population has increased to 350 million from about 320 million in 1970 and since 1988 the 
rate of growth has slowed to about 1.5 million a year. The population structure by 5-year age groups 
for the Community in 1970 and 19*93 is shown in Fig. 2.1.1. The smaller number of children compared 
with young adults in 1993 is due to the particularly sharp drop in an already falling birth rate in the 
early 1970s. There are roughly similar numbers of men and women in each age group up to the age 
of 55, but at older ages women outnumber men. 
Births 
The falling fertility rate is a world-wide population trend. In the Community, total fertility rates (the 
expected number of births per woman age 15-44) began to fall in some, mainly northern, countries 
towards the end of the 1960s (Fig. 2.1.2). The fall coincides with oral contraceptives first becoming 
available, and probably reflects several social trends - increasing labour participation among women, 
people choosing smaller families, delaying the start of families or choosing not to have families at all. 
Rates in these countries stabilized later, but by then, other countries were also seeing a fall in their 
fertility rates. Within the Community, Spain and Italy now have the lowest fertility rates (1.2 child per 
woman). (1) Although the Community has lower rates than other groups of countries (overall 1.5 child 
per woman), the most recent data appear to suggest a tendency towards an increase in these rates for 
some EC countries. However, for the Community as a whole, the decrease is still the dominant trend 
(down 0.1 child for the period 1990 -1993). 
Those data available on contraception show that the contraceptive pill is most widely used, followed 
by condoms. But there is some evidence that the use of condoms among young people has been 
increasing owing to their promotion in AIDS information campaigns. Male and female sterilization is 
increasing for couples towards the end of their childbearing period, and is now used by up to 25% of 
couples in Belgium and the United Kingdom. 
In the Community, abortion is legal, except in the Republic of Ireland and in Northern Ireland in 
the United Kingdom. The ratio of recorded abortions to live births in EC countries varies from one in 
ten in the Netherlands and Spain, to one in three in Denmark and Italy, though these figures need to 
be treated cautiously because of differences in terminology and recording practices. Most women who 
have abortions are in their 20s and 30s. 
Ageing 
Both the high birth rates in the early part of the 20th century and increasing survival have contributed 
to the rising numbers of older people in the Community. Noi only has there been a rise in absolute 
terms, but the proportion of those over 65 in the Community, and especially the very old (85+), has 
increased over the past two decades and is now among the highest in the world. Together with falling 
birth rates, this ageing of the population affects "dependency".' In 1992. the dependency ratio for the 
Community. 49 per 100 aged 15-64. was lower than that for North America (52). the Nordic countries 
(53) and the countries of central and eastern Europe and the former Soviet Union (53) (2). 
The proportion of those aged 65 and over is projected to rise from 15% in 1995 to 17.1% by the 
year 2010. while the proportion of adults aged 15-64 is expected to decline from 67.1% to 65.6% over 
the same period, with the proportion under 15 remaining relatively stable (3). This, coupled with the 
fact that more women in the age group 15-59 years are now in full or part-time paid employment - a 
rise in the Community from 47% in 1980 to 54% in 1989 - suggests that there may in consequence 
be fewer opportunities for informal care from this age group, adding to the demand on the caring 
services. 
Migration 
Around 6 million EC nationals (2%) live in other EC countries, with the highest proportion in 
Luxembourg and Belgium. Every year some 350 000 people (one per thousand) move from one EC 
country to live in another. 
Net immigration from outside EC countries was low in the early 1980s but has increased more 
recently to about 1 million people a year. Germany is the major host country, the United Kingdom has 
net emigration. In 1992. the leading countries from which immigrants came to the Community were 
Poland, Turkey, the former USSR and Yugoslavia. 
In the Community in 1992 more than 10 million people were non-EC citizens, about 4.4 million of 
whom were living in Germany. Nearly half of the 10 million non-EC citizens were citizens of other 
European countries (including Turkey). 2.8 million were from African countries, 1.6 million from Asia 
and 0.8 million from the American continent. 
Migration is one example of social and cultural change, and the health of migrants is dependent on 
a number of factors, including the reasons for their migration, the culture and lifestyle of their country 
of origin and their host country and the experience of being migrants. Therefore, patterns of health and 
disease in migrants may differ from that in the host population. Refugees and asylum-seekers in 
particular might have a traumatic background, giving rise to needs for specialised treatment in the host 
country. However, information on the ethnic origins of the population is a sensitive issue, and data for 
the Community are lacking. If such data were available, they could help to identify the services needed 
to meet specific health problems related to ethnic origin. 
Dependency is a purely demographic description, defined as the ratio of the number of people aged 0-15 
and 65-*- to those aged 15-64. 
2.2 Life expectancy: 
Europeans are living longer 
Year by year. Europeans are living longer. Since 1970. life expectancy - the age that a newborn child 
may expect to reach given current death rates - has increased in all EC countries (Fig. 2.2.1). Life 
expectancy in the Community rose from 71.8 years in 1970 to 76.5 in 1991. The difference between 
men and women widened over this period: the male average rose by 4.5 years from 68.6 to 73.1 years, 
while the female average rose by 5 years from 74.9 to 79.9 years. For older people, who have reached 
the age of 65. life expectancy in the Community rose from 14.6 years in 1970 to 17.1 years in 1991 -
an extension of two and a half years of life. As we look forward to further life expectancy increases, 
issues surrounding the quality of Hfe and healthy aging are beginning to come to the fore, with a new 
emphasis being put upon 'healthy life expectancy' and "disability free life expectancy', together with 
a growing concern about the impact on the health and social services in all countries of the increasing 
numbers of older people. 
The variations between industrialized countries in terms of life expectancy and general economic 
development (as measured by real GDP) can be seen in Fig. 2.2.2. Economic development is not the 
only factor involved in such variations, especially for the EC and other EFTA and OECD countries. 
High life expectancy has been achieved by some southern Community countries which currently have 
relatively low real GDP. such as Portugal where life expectancy increased by over 7 years to 74.4 years 
between 1971 and 1992 (Table 2). 
On the other hand, the expectation of life in EC countries is not the highest in the world. Among 
developed market-economy countries. Japan, Iceland, and Switzerland all do better than the best EC 
country. France (which has the same life expectancy as Canada), while Denmark. Ireland and Portugal 
rank below the USA and New Zealand (Fig. 2.2.3). Japan, in particular, is of interest: in 1970 it ranked 
ninth, whereas by 1992 it was in first place, with an increase in life expectancy of 6.5 years over the 
period. 
The increased expectation of life between 1970 and 1991/92 has not been uniform between 
countries. France, in increasing its life expectancy by 4.8 years, has overtaken Greece, the Netherlands 
and Denmark to become the country with the longest life expectancy in the Community. In contrast, 
Denmark has had only a small improvement (1.9 years): an investigation in Denmark has shown that 
the relative deterioration is across several disease groups. These include heart disease and lung cancer 
with the high smoking rate, established in both men and particularly women for over 40 years, being 
an important contributing factor. The proportion of women who smoke is higher in Denmark (42 %) 
then in any other country in Europe. 
A further way of looking at what might still be achieved is to use a hypothetical model based on 
the best mortality rates at different ages from each of the countries across the whole of Europe. 
When compared with the current average age-specific mortality rates for the Community (Fig. 2.2.4), 
it shows the improvement possible if the EC countries were to match the best age-specific mortality 
rates being achieved in Europe. There is scope for improving survival, particularly among the middle 
and older age groups. In their recent population forecasts, a number of the countries expect c 
considerable increase in their life expectancies in the years to come. 
2.3 Differences persist 
Age is the single factor most closely associated with death rates, but there are also other groupings 
which show important differences in mortality. 
Sex 
In all EC countries, women live longer than men. Women have fewer deaths from accidents and 
violence, and their death rates from heart disease and stroke rise with age more slowly than men.4 
The mortality difference between women and men is probably not just inborn: it also reflects 
different behaviour by men and women, particularly consumption of alcohol and tobacco, and risk-
taking behaviour e.g. in driving. In the Community in 1991. there were three times as many deaths in 
men aged 15-34 (65 000 deaths) compared with women of the same age (23 000 deaths). Fig. 2.3.1. 
shows how the excess of deaths in men has developed in France during this century. In the 1920s 
deaths in men were only a little greater than in women, and in adolescence the picture was actually 
reversed. However, by the 1960s, the higher death rates of men at all ages (and especially young 
adults) can be seen, and these differences have increased up to the present. Whether these differences 
will continue in future is open to question, given for example the rising smoking rates in women (see 
section 4.1). 
Social groups 
Differences in death rates between social groups are present in all countries. Whether the ranking is 
by occupational group, for example "white-collar" (nonmanual) compared with "blue-collar" (manual) 
groups in Germany (Fig. 2.3.2), social class (Fig. 2.3.3), educational level or income, differences 
between groups are found. Inequalities in health may also be increasing. In the United Kingdom, 
although mortality declined for all social classes (grouped by occupation in the ten-yearly census) 
between 1951 and 1981, the gap between the standardized mortality ratios of males with professional 
and unskilled occupations appears to have widened (Fig. 2.3.3). These differences exist despite the 
availability of health services, through social insurance or national health systems, for all social groups 
in EC countries. However, data on the pattern of use or uptake by social groups are generally not 
available. 
Geography 
There are marked local variations in death rates within EC countries. Fig. 2.3.4 shows standardized 
mortality ratios (SMRs) in local administrative areas of Member States in 1980-1984. There are also 
variations for specific causes of death. It is difficult to draw any firm conclusions, but in general 
favourable patterns seem to match rural areas in southern countries, while unfavourable patterns are 
found in industrial conurbations of northern countries. 
In interview surveys, women report more symptoms of physical and mental illnesses than men (4); this 
difference has been described as "quantity of life but not quality". 
Within regions and conurbations there are also geographical variations: some inner areas of older 
cities or peripheral areas with decaying public housing have higher death rates than affluent suburbs. 
Chapter summary 
The EC population has been growing slowly in size, and there are fewer children and more older 
people. People are living longer, but further improvement is possible through reducing disease in 
middle and older age. Differences in death rates by sex, social groups and geography persist. 
References 
EUROSTAT Demographic statistics 1994. Luxembourg. 1994. 
UNDP. Human development report 1994. New York, 1994. 
United Nations. World population prospects. The 1992 revision. New York, 1993. 
For example. Smyth, M. & Browne. F. General household survey 1990. London. 
Office of Population Censuses and Surveys, 1992; and Ruwaard, D. et al. Public health 
status and forecast: the health of the Dutch population over the period 1950-2010. The 
Hague, Rijksinstituut voor Volksgezondheid en Milieuhygiene. 1994. 
Chapter 3 
Patterns of health, disease and 
disability 
The incidence of and mortality from different diseases varies significantly by age. At the international 
level, information on incidence is limited, even for indirect measures such as admissions to hospitals 
and contacts with primary care. Mortality information, however, can be used to show the age profile 
of the main causes of mortality (Fig. 3.Ô.1). although it should be noted that only about a fifth of all 
deaths are before the age of 65, and only just over one in a hundred before the age of 15 years. 
Cross-sectional analysis at different age bands allows a more detailed analysis of the major patterns 
of disease, and this chapter reviews these patterns by the stages of the life cycle, as depicted in Fig. 
3.0.2 .5 Accidents and suicide are the most common causes of death in young people. Cancers 
and cardiovascular disease begin to dominate in middle age, with cancers most frequent in late 
middle age. Cardiovascular diseases account for nearly 50% of all deaths over 65. Disability 
from chronic diseases is also a major concern for older people. 
3.1 Children (0-14 years) 
Deaths of children have fallen over the past 20 years, continuing a process that started early in the 
century. The infant mortality rate for the Community has halved, from over 20 per 1000 live births 
in 1970 to under 10 per 1000 in 1992. and the large differences between countries in 1970 have dim­
inished (Fig. 3.l.l). This is mainly the result of better child care, care in pregnancy and intensive 
neonatal care; but some perinatal problems remain. 
Congenital anomalies cause about a quarter of all infant deaths in the Community'. New 
technologies in genetics and investigation of the foetus at an early stage in pregnancy can allow control 
of these diseases. Genetic counselling in relation to conception can assist in the context of the former, 
while selective abortion (with proper safeguards) may be an appropriate response to the latter where 
permitted by national legislation. However, medical practice needs to be in line with public opinion, 
and the important ethical and cultural issues need wide debate. Screening programmes for genetic 
abnormalities must offer enough information for people to make choices for themselves. For this 
approach to be successful, there should also be sufficient counselling and support. 
Intensive neonatal care of premature babies reduces perinatal death rates but may increase 
postneonatal death rates. Severely premature babies that survive through intensive care are at risk of 
higher rates of mental and physical handicap than less premature ones. Specific groups, often living 
in deprived city areas with low incomes and sometimes within migrant and refugee communities, may 
have poorer maternal and child health. Preventive care and maternity services need to reach these 
groups effectively. 
The subcategories chosen account for a large part of mortality and are primarily those which are 
"preventable" through public health action. 
10 
Much of the burden of chronic disease in children results from birth trauma and congenital 
anomalies. Down's syndrome is the most common cause of severe learning difficulty, and cystic 
fibrosis a common cause of severe lung disease. Two haemoglobin disorders, thalassaemia and sickle 
cell anaemia, have important health consequences. The high prevalence of the former in Greece and 
Italy can be seen in Fig. 3.1.2. 
Dental health 
There has been a marked improvement in children's dental health. The average number of decayed, 
missing and.filled permanent teeth (DMFT) in 12 year-old children has fallen in all countries except 
Spain. Fluoride toothpaste and education for regular cleaning, together with addition of fluoride to 
water supply, have contributed to this change. Denmark and the Netherlands, which introduced 
systematic preventive programmes for child dental care, have moved from having among the worst 
average DMFT at this age to the best (Fig. 3.1.3). 
Childhood infectious disease 
Childhood infectious diseases are being controlled through the delivery and maintenance of 
immunization programmes. The Netherlands had an effective system throughout the 1980s: Denmark, 
Luxembourg, Portugal, Spain, and the United Kingdom introduced MMR (mumps-measles-rubella) 
vaccine in the second half of the 1980s, with substantial reductions in infections. Coverage of children 
with measles vaccination in 1992 was 94% in the Netherlands, 83% in Spain and only 50% in Italy. 
The differences in these national programmes are demonstrated in Fig. 3.1.4, where the Netherlands 
has a continuously low level of recorded disease and Spain a fall in the late 1980s, while Italy has 
continued to have epidemic fluctuations. 
Accidents 
Accidents are the leading cause of death in children aged 1-14 and a significant cause of disability. In 
children under 5 most accidents occur in the home, while for older children most accidents occur where 
they play or on the roads. Preventive measures include health education from a very early age and 
supervision. Much can also be done to make environments safer, including safety measures specifically 
for children. 
Cancer 
Cancer in children aged 1-14. although representing less than 0.3% of all cancers, is the second leading 
cause of death at this age. The incidence is rising in parts of the Community, but death rates are falling 
due to effective drug treatment of leukaemia and some solid tumours. 
Mental health • 
The emotional wellbeing of children, especially in deprived city areas can give rise to concern. Child 
physical and sexual abuse by parents, other children and carers is now beginning to be recognized as 
a significant issue, but accurate statistics are not available. It is thought that abuse in childhood can 
contribute substantially to subsequent adult emotional and behavioural problems. More open discussion 
of these issues is needed, and new strategies for dealing with them must be found. 
11 
The European Network of Health Promoting Schools is a joint action between WHO. the 
Council of Europe and the Commission. 
All EC Member States are now in the network. Countries and school teams implement projects 
to tackle issues which are important locally and at the same time have European relevance. 
These projects will be evaluated and used as models of good practice. 
3.2 Young people (15-34 years) 
Young people are the healthiest group in the population. They have fewer disabilities and they are 
more informed about health issues. However, it is at this age. and especially during adolescence, that 
forms of behaviour harmful to health can develop Information on adolescent behaviour and attitudes 
can be gained through surveys. The results of a WHO collaborative study are shown in Figs 3.2.1 and 
3.2.2. These forms of behaviour are important factors for the risk of disease in adult life, and it is of 
concern that smoking in girls in some parts of the Community is now rising to the same level as that 
of boys. The rapid and dramatic increase in daily smokers between the ages of 13 and 15 years 
indicates an important focus for anti-smoking campaigns. 
Forms of adolescent behaviour creating health risks are inter-linked: the smokers are more likely 
also to be drinkers, take less physical exercise and have poorer diets (1). These forms of behaviour are 
also related to how adolescents think of themselves, their involvement at school and their relationships 
with their parents. Young people with similar views and behaviour seek each other for identity and 
acceptance, forming subgroups with strong peer group cultures. 
Unprotected sexual behaviour may expose some people to unwanted pregnancy, sexually-
transmitted diseases and HIV infection. There are almost a quarter of a million births a year to women 
aged under 20 years in the Community. The rates are falling (Fig. 3.2.3) in all EC countries except 
for the United Kingdom and the Netherlands. However, rates are lowest in the Netherlands. 
Accidents 
Mortality' from external causes accounts for more than half of all deaths in the age group 15-34; of 
these, almost half are deaths from motor vehicle accidents. Such accidents are the most frequent single 
cause of death and disability in this age group. Young people also account for 45% of all motor vehicle 
accidents, followed by middle-aged adults (age 35-64). 
About 50 000 people are killed, and one and a half million people are injured, each year on roads 
in the European Community. Road accidents are the leading cause of death in young adults (aged 25-
34) and are therefore a major cause of lost working potential. Data from the United Kingdom shows 
that pedestrians are mainly killed by cars, while car occupants are killed alone or in collision with other 
cars or heavy goods vehicles (Fig. 3.2.4). 
Over the past twenty years there have been falls in road accident death rates in most EC countries 
but there is a rising trend in Greece and Spain, and rates remain high in Portugal (Fig. 3.2.5). 
The trends in injuries are rather different. Denmark, France, Luxembourg and the Netherlands show 
improvements in both death and injury rates, while others (e.g. Belgium and the United Kingdom), 
show improving death rates but little or no improvement for injuries (Fig. 3.2.6). It is not known 
whether the countries with a fall in deaths or injuries have had fewer seriously disabled people as well: 
data on the severity of disabilities resulting from traffic accidents are not routinely recorded. 
12 
The Commission has proposed a road safety programme including : 
* establishing a Community data bank for monitoring and research 
* vehicle passenger protection 
* education of road users 
* sensible driving, including limiting speed and alcohol misuse 
* road design improvements 
Accidents other than road accidents and occupational accidents across the Community are reported 
in a sample survey of hospital accident departments or, in certain Member States, by a household 
survey (the European Home and Leisure Accidents Surveillance System). About one in three accidents 
is reported as "play and leisure", especially among children, and one in six accidents involves sports, 
most commonly in young adults. The majority of leisure accidents are falls and involve injuries to the 
arms and legs. The proportion of people admitted to hospital increases from 5% in children to 15% for 
people over 65. The survey is particularly useful for identifying accidents resulting from home and 
leisure consumer products, offering opportunities for prevention through better design. 
Homicide 
One indicator of broader social pathology is the homicide rate. Deaths from homicide in age groups 
15-34 and 35-64 account for nearly 85% of all homicides; they are more frequent in men than in 
women. The age group 20-34 has the highest rates for men. The Community average, excluding 
Portugal and Italy, remained more or less unchanged between 1970 and 1990 (Fig. 3.2.7). 
3.3 Adults (35-64 years) 
In the Community, more than 600 000 adults (age 35-64) die every year; four out often die from 
cancer, three from cardiovascular disease and one out often from external causes (mainly suicides and 
accidents). These deaths are preventable and offer the greatest potential for further improvements in 
life expectancy in the Community'. 
Cancers 
Cancer is the main cause of death for adults and accounts for 4 out of every 10 deaths in the age group 
35-64 compared to 2 out of 10 in the age group 65+. Cancers occur most frequently in the lungs and 
prostate in men. and in the breasts and lungs in women (Fig. 3.3.1 ), and these cancers are also the most 
frequent causes of all cancer deaths. Many preventable factors contribute to the onset of cancer, notably 
smoking (especially of lung cancer), and survival from other cancers (e.g. cervical and breast cancer) 
can be improved through early detection. 
Lung cancer 
Many people dying from lung cancer in the 1990s started smoking in the 1950s and 1960s. At present 
there are many more deaths in men than in women in the Community, because men have been smoking 
for longer and are heavier smokers. Lung cancer death rates in men under 65 ?re rising in France, 
Greece. Portugal and Spain (Fig. 3.3.2). However, the male death rate has halved in the United 
Kingdom since 1970 and there is a similar, if less dramatic, steady fall in the rate for the Netherlands. 
Rates were also falling in Ireland and Italy in the late 1980s. 
13 
In sharp contrast to the trends for men. women's lung cancer rates, although much lower than rates 
in men. are rising in many countries as a result of increasing smoking by women (Fig. 3.3.3). In 
Denmark, where about 40% of women have been smoking since the 1950s, lung cancer death rates are 
now approaching those for breast cancer. 
Breast cancer 
Breast cancer is the most common cancer in women. About 2-3% of women in the Community develop 
this cancer during their lifetime and 70 000 die each year. About a quarter of women newly diagnosed 
with breast cancer are under 50. but average survival is relatively good (around 60% at 5 years), after 
diagnosis and treatment. Most women dying from breast cancer (nearly 60%) are of retirement age 
compared to 40% in the age group 35-64. The incidence of breast cancer is rising in most EC countries 
(Fig. 3.3.4). The causes of breast cancer are poorly understood. 
Cancer of cervix 
Cancer of the cervix causes about 7500 deaths in women in the Community each year, with roughly 
half of these deaths in the 35-64 age group and the other half in the over-65s. Risk factors include 
early sexual activity, multiple sexual partners and cigarette smoking. Screening and early intervention 
greatly improve survival. Denmark and the United Kingdom have higher death rates than other 
countries, but rates are static or falling in all countries except Greece and Spain. Screening is 
undertaken in EC countries for both cervical and breast cancer and it can reduce mortality from these 
diseases. However, screening programmes need good management to ensure satisfactory population 
coverage and quality. 
Cancer of the ovary 
Cancer of the ovary causes twice as many deaths as cancer of the cervix, since only one in three 
women with this cancer survive five years. Incidence and death rates are higher in northern than in 
southern countries. Little is known of the causes of ovarian cancer, although oral contraceptives appear 
to have some protective effect. 
Stomach cancer 
Stomach cancer causes about 1% of all deaths, and 5% of cancer deaths, in the Community each year. 
There has been a notable decline in stomach cancer over the past 20 years. This trend started earlier 
in the century in most EC countries, although later in Spain, and mortality in Portugal was still rising 
until 1970. Death rates in Portugal are still almost twice as high as most other EC countries. Denmark, 
France and Greece now have the lowest rates in the Community (Fig. 3.3.5). Rates in women are half 
those in men in all countries. 
Stomach cancer still has a poor survival rate once diagnosed, as only about one in twenty people 
live for more than five years after diagnosis and treatment. The falling incidence of stomach cancer 
is probably related to changes in dietary patterns, especially people eating more fruit and vegetables 
and more refrigerated, rather than preserved, food. 
14 
Europe Against Cancer: the Second Action Programme (1990/1994) included : 
* an anti-smoking campaign 
* action to improve eating habits 
* development of systematic screening and early diagnosis for breast and cervical cancer 
* contribution to directives for protection against carcinogenic agents 
* The European Code against Cancer 
* development of a European network on cancer data 
Cardiovascular disease 
Mortality from cardiovascular disease (CVD) accounts for nearly 45% of all deaths in the Community. 
Middle-aged adults in the age group 35-64 are the main group affected after the over-65s. This disease 
accounts for nearly half of all over-65 mortality. 
Coronary heart disease 
Coronary heart disease, in addition to being the main cause of CVD mortality, is the largest single 
cause of death for people in the Community - around 17% of all deaths - and is a major cause of 
morbidity and disability. Changes in the prevalence of the disease thus have an important effect on the 
population's overall life expectancy and level of health. 
Many coronary heart disease deaths are sudden: after a heart attack, about one in three people die 
suddenly, and another 10-20% within the next days or weeks, while the rest survive. New treatments 
include drugs to reduce blood clotting (both specific enzyme treatment given urgently after the attack, 
and aspirin and other drugs for longer-term treatment). Another important factor in longer-term survival 
is patients stopping smoking. 
Death rates from coronary heart disease have been falling in most countries, especially over the past 
10 years (Fig. 3.3.6), both in men and women. This has been more marked in northern countries, 
where there were high rates in the 1970s. Rates in Belgium have almost halved in 20 years. Greece 
is the only country in the Community showing a rising trend over the period. 
Population surveys that monitor risk factors for heart disease at local level, and registers that collect 
information on disease rates, are available for several centres. Initial data on risk factors for some of 
the centres in EC countries are shown in Fig. 3.3.7, while the rates of heart attack are shown in Fig. 
3.3.8. 
Stroke 
There are about half a million deaths from stroke (cerebrovascular disease) in the Community each year 
(one in seven of all deaths). Most strokes are due to damage, either bleeding or a clot, of blood vessels 
in the brain. As with heart disease, there has been a substantial fall in death rates in most EC countries, 
with a particular improvement in Portugal, which started the early 1970s with very high rates (Fig. 
3.3.9). The relative trend in Denmark has been the opposite: it had the lowest rates in the Community 
in 1970. but by 1990/91 it had a higher mortality r»te than several EC countries and higher than the 
EC average. 
15 
The falling trends in both heart disease and stroke are partly related to improvements in diet, 
including changing salt intake, less cigarette smoking, and management of high blood pressure, as well 
as treatment after heart attacks. 
Liver disease 
About one in 50 deaths in the Community is due to liver diseases and cirrhosis. The trends in death 
rates for liver cirrhosis in EC countries are shown in Fig.3.3.10. France stands out with a marked 
falling trend: similar although less marked trends are seen in other major wine-producing countries 
where consumption is also falling - Italy. Portugal and Spain. In Greece the pattern is less clear, as 
there has been a falling death rate from liver disease accompanied by a small rise in alcohol 
consumption. Of other EC countries, the patterns in Denmark and the United Kingdom are of concern. 
In both these countries, alcohol consumption has been rising and cirrhosis deaths are also increasing 
(see also section 4.1). 
Other chronic diseases 
Many of the diseases of adult life do not show up directly as causes of death. Good medical care 
continues to make an important contribution to limiting the progression of disease and its symptoms. 
Data on the prevalence of chronic disease are lacking, but Fig. 3.3.11 gives some estimates based on 
various localized studies. 
* Joint conditions are a major cause of disability. Rheumatoid arthritis has a slow and variable 
course: it may be helped, but not usually cured, by drug treatment. Osteoarthritis is the "wearing 
out" of the joints: replacement of hips and knees has been a successful medical advance. 
* Treatment of chronic kidney disease is life-saving. Treatment can entail either dialysis or kidney 
transplantation. There has been cooperation at European level for several years, both in exchanging 
kidneys for transplantation across country borders and in sharing data on services and outcomes. 
* There are two forms of diabetes. In children and young adults the onset is sudden, and insulin is 
life-saving (there is an unexplained high incidence of insulin-dependent diabetes in Sardinia). 
Diabetes develops more slowly in older adults. Its onset is related to obesity and a diet with high 
sugar intake. Good control of diabetes, by collaboration between physicians and patients, can 
reduce complications, including blindness, kidney failure and arterial disease of the limbs. 
* The prevalence of asthma and of bronchitis is related to smoking and urban air pollution (e.g. from 
cars). Asthma prevalence appears to be rising. 
* About one in two hundred people in the population have established epilepsy, but over a lifetime 
up to 3% of people may experience at least one fit. For the majority of people, fits can usually be 
controlled through correct medication. 
Occupational accidents and diseases 
There are about 6500 deaths due to occupational accidents each year. The reported rates, although 
based on systems that differ in definitions and coverage, show considerable variations between 
countries (Fig. 3.3.12). 
16 
About one in ten of the 120 million workers in the Community suffers an industrial injury or an 
occupational disease every year. Common conditions include accidents, hearing impairment, chemical 
poisoning, ergonomie problems (especially back strain) and psychological stress. Data from France and 
Germany show patterns of permanent disability in different industries (see Fig. 3.3.13). and these 
mirror mortality patterns, with most deaths in the mining and construction industries and in agriculture 
and transport. 
Health promotion in the workplace on forms of health-related behaviour, including smoking, 
drinking and exercise, will benefit both employers and the population in general. Occupational health 
services are available to only 50% of employees and are generally not provided to employees of small 
enterprises. 
Health and safety' at work is an important concern of the Community. The first directive, based 
on Article 100 of the EEC Treaty, was adopted in 1977. In 1989 a framework directive 
(89/391/EEC) was adopted on broad aspects of health and safety' at work; and there are 
12 "daughter" directives on particular aspects of occupational safety and health. 
Infections 
HIV/AIDS 
The acquired immunodeficiency syndrome (AIDS) is a sexually transmitted disease which can also be 
transmitted through blood (via the transfusion of infected blood or blood products or through the use 
of non-sterile injection equipment) and from an infected woman to her fetus or infant. Transmission 
through sexual intercourse between men continues to be a significant mode of spread in many 
countries, as does transmission through the sharing of non-sterile needles and syringes by injecting drug 
users. AIDS appears to be fatal, but there is a delay of about 10 years or more between initial infection 
with the human immunodeficiency virus (HIV) and development of the clinical illness of AIDS. 
Notified cases of AIDS are rising in all EC countries, with annual rates of new cases being by far 
the highest in France. Italy and Spain (Fig. 3.3.14). Up to the end of 1994, more than 120 000 AIDS 
cases were diagnosed throughout the Community: 73% of these were in the above-mentioned three 
countries, followed by Germany and the United Kingdom with 10% and 8% of the total cases, 
respectively. These figures reflect only a small part of the problem, however, because of the long 
incubation period. Availability of data on the incidence and prevalence of HIV infection is limited. One 
way of collecting information in order to determine the prevalence of HIV infection is anonymous 
testing (serosurveil lance) of patients attending for treatment of sexually transmitted diseases or antenatal 
care, for example. However, such HIV surveillance exists in only a few countries, partly due to 
characteristics of their health systems and perhaps also related to ethical considerations. According to 
the latest estimates of the cumulative incidence and prevalence of HIV, around half a million persons 
were considered to be HIV-positive bv the end of 1993. 
17 
The distribution of cumulative AIDS cases (adults/adolescents) by transmission group shows wide 
differences between countries (Fig. 3.3.15). In northern Europe (e.g. in Denmark, Germany, the 
Netherlands and the United Kingdom), homo/bisexual men are the transmission group with the highest 
proportion (69 to 75%) of all AIDS cases. In some of the southern countries, particularly Italy and 
Spain (which are among the countries with both the highest annual and cumulative incidence), injecting 
drug users are the predominant transmission group (66%). homosexuals accounting only for about 15% 
of the total cases in each country. Infection from blood products or as a result of transfusion is now 
rare and accounts for a diminishing proportion of all AIDS cases, whereas the proportion of AIDS 
cases transmitted through heterosexual contact, and from women to children, is increasing. People in 
prisons are particularly at risk of HIV infection from sex between men or drug use. Also, unsafe sexual 
behaviour while on holiday or business trips can be a way of HIV transmission, and such travel is 
currently expanding. 
Europe Against AIDS has a programme of action 1991/1994 including : 
* collection of data 
* surveys of. and information to. the public 
* measures for children and young people 
* prevention of HIV transmission 
* social and psychological support 
* combatting discrimination 
Transmission of HIV is preventable through known methods - "safer sex" practices, sterile 
injecting equipment, and screening blood for transfusion and blood products. 
Other infectious diseases 
Other infectious diseases continue to cause significant health problems in adults: 
* Tuberculosis notifications have generally been falling in EC countries; Fig. 3.3.16 indicates trends 
for a selected number of EC countries. There has been a substantial improvement in Germany and 
Greece but rates remain high in Portugal. There was an increase in notifications in Spain during 
the early 1980s, and this seemed to be the case again in the early 1990s. The decline in some other 
countries has stopped, perhaps as a result of increased immigration and TB developing in people 
with AIDS. Anti-tuberculosis immunization programmes exist in only some EC countries. 
* Hepatitis B is most frequent in Portugal and Italy. Italy has a universal immunization programme. 
Spain's programme is planned to cover 14 of its 17 regions by 1994 and the remainder by 1997. 
Portugal has similar plans, whereas other countries have or are planning programmes for high-risk 
groups only. 
* Foodborne infections are an increasing problem, indicated by rising trends in France and the United 
Kingdom (some countries do not record these data). The sources of infection can be within the 
foods themselves, including chicken and eggs infected with Salmonella and some milk products 
infected with Listeria. Actions are needed aiming to promote good hygiene in preparing food at 
home and for sale. 
* Malaria is becoming a frequent infection in the Community, with a rising incidence in Belgium, 
France. Greece and the UK. 
18 
Mental illness 
At any one time, about 10% of the population are estimated to have a mental illness, most commonly 
mild depression or anxiety. Mild mental illnesses are present in between a third and a half of 
consultations in general practice, although patients may initially present with physical rather than 
emotional problems. A wide range of social factors contribute to mental illness. Depression is more 
common in women with young children, and in bereavement. Schizophrenia, while found less 
frequently in the population, has a more persistent chronic course, and patients with this condition need 
continuing psychiatric care and supportive social settings to prevent relapse. 
Suicide 
There are about 40 000 deaths from suicide in the Community each year. There are four- to five-fold 
differences in suicide death rates between countries. The rates were increasing between 1975 and 1985 
in Belgium. Denmark. France, Italy and the Netherlands, but subsequently fell again (Fig. 3.3.17). 
Rates in Germany fell substantially during the 1980s. Ireland and Spain have seen a rise towards the 
rates of other countries, whereas rates for Greece have remained low. All these figures need to be 
interpreted with care, however, as cultural differences may influence the reporting of suicides. 
Suicides are more common in older people, more frequently men. Depression and alcoholism are 
the two major background factors, while a physical disease (for example, terminal cancer) is less 
common. Many people who commit suicide have been in contact with a doctor and may have received 
drug treatment, although not necessarily drugs for depression. Earlier diagnosis of depression by 
general practitioners and appropriate treatment, combined with strategies to combat social exclusion, 
could have a significant impact on suicide rates. 
Attempted suicides ("parasuicide") not leading to death are more common in younger people and 
are more usually found in women. A WHO collaborative study is measuring parasuicide rates in several 
Community countries (Fig. 3.3.18) and, like the suicide mortality pattern, frequency is higher for 
Denmark and France and low for Italy and Spain. 
3.4 Older People (65+ years) 
While 65 years is often taken as the start of older age, ageing is a continuous process which varies 
considerably between individuals - some people remain fit well into their 80s. In the Community', there 
are roughly the same number of people aged over 75 as between 65 and 75. The very elderly are 
predominantly women, and widows: women usually marry men older than themselves and they also 
live longer than men. They have often cared for their husbands at the end of their life, but then live 
alone. 
Life expectancy of older people has increased steadily in EC countries, with France leading and 
Denmark showing a much slower increase than other EC countries (Fig. 3.4.1). The main causes of 
death in older people are cardiovascular diseases and cancers, which account for over 70% of all deaths 
in this age group. Although most older people are not disabled, the majority of disabled people are 
elderly. At least 20 million EC citizens are estimated to have a disability severe enough to receive 
some kind of benefit (payment or assistance). 
19 
Some diseases in older age need special attention. Physical disabilities, especially arthritis and 
chronic heart disease. frequentK limit the ability of older people to care for themselves. Support is also 
needed for impaired hearing, foot complaints and incontinence, which all affect the quality of life in 
old age. There is improving dental health of older people. For example, in Denmark, the United 
Kingdom and Ireland, the proportions of people aged 65-74 without any natural teeth fell by 10%. 12% 
and 23%. respectively, between 1985 and 1990. Dementia increases with each decade of life: 
European-wide surveys show that up to 25% of people aged 85 and over have some clinical dementia. 
Support for informal carers as well as for the person with dementia is the primary need. 
Chapter summary 
Most children are healthy, and more attention is being paid to the control of inherited disorders. In 
adolescence forms of behaviour are developed which may contribute to disease later. Young adults 
have high death rates from road accidents, while heart disease, stroke and cancers (especially lung and 
breast cancers) are the main health problems of middle-aged and older adults. Deaths from occupational 
accidents are relatively low. but industrial injuries and occupational disease affect one in ten workers. 
The incidence of AIDS is growing. 
Health-related behaviour - smoking, alcohol, drugs, exercise, nutrition and sexual behaviour - are 
important risk factors for these diseases. Together with other determinants - such as the environment 
and social and health service provision - they are considered in the next chapter. 
References 
1. KING. A.J. & COLES. B. The health of Canada's youth: views and behaviours of 11, 13- and 15-
year olds from 11 countries. Health and Welfare Canada. 1992, p. 90. 
20 
Chapter 4 
The determinants of health 
The health and ill health of people in Europe has so far been described through the main diseases. 
However, most diseases have several determinants, each of which contributes a part to the overall 
pattern of disease. This section looks at the behavioural, environmental and social determinants of 
health and at the role of health services. 
Addictions such as cigarette smoking, alcohol misuse and drug abuse, as well as bad diet, contribute 
to the main causes of premature death. The quality of the immediate and the more general external 
environment (e.g. housing, transport, air, water and waste) is of increasing public concern, and 
improvements here also contribute to health. Social issues include employment, poverty and leisure as 
well as social marginalization and exclusion. The health services undertake health promotion and 
protection as a part of primary care, for example through immunization and screening programmes, 
as well as at the level of national policies. 
4.1 Health-related behaviour 
The high levels of premature deaths and the prevailing trends in those rates underscore the need to 
examine the pattern of risk factors for heart disease, stroke, cancers, liver disease, accidents and mental 
health: these include tobacco smoking, alcohol misuse, drug abuse, bad diet, lack of exercise and 
exposure to ultraviolet radiation. 
Tobacco 
The effects of smoking on a population are dramatic. In the first years, the health effects are relatively 
invisible and unrecognized. It is only up to 40 years later that the full effects are seen. It has been 
estimated that one in two teenagers starting to smoke now could die from tobacco if he or she 
continues to smoke steadily. 
Cigarette smoking also contributes substantially to deaths from lung and heart diseases in particular. 
At present, only one in five smoking-related deaths is in women, because they have not been smoking 
as long as men and are less heavy smokers. Overall, in 1990, it has been estimated that smoking 
contributed to half a million deaths with one in three deaths in males aged 35-64, and one in five in 
males aged 70+. For women in these age groups, smoking led to one in ten and one in twenty deaths, 
respectively. 
In the Community in 1992, 42% of men and 28% of women aged 15 and over were smokers 
(Fig. 4.1.1). Smoking rates in younger women are higher than in older women and are approaching 
the same levels as in men. Of current smokers, more than one in two men and one in five women 
smoke 20 or more cigarettes a day. In the last decade, most countries have seen a decline in men 
smoking but an increase in women doing so. 
A recent survey in the Community revealed that, of the 72 million current smokers, two in three 
had tried to stop once or several times, and one in three - 23 million people - wished to stop now 
(Fig. 4.1.2). 
21 
Directives to control tobacco products include: 
* display on packets and advertisements of: 
maximum tar yield of cigarettes (1990): 
health warning and tar and nicotine content ( 1989); 
* ban on advertising tobacco products on television (1989): 
* minimum taxation 57% of retail price of most popular brand (1992). 
A resolution of the Council and the Ministers of health assembled in the Council invited Member 
States to ban smoking in places open to the public, including public transport (1989). 
Retail prices are influenced by tax policies and Fig. 4.1.3 shows the range of tobacco prices 
between different countries, indexed for local general price levels. 
Alcohol misuse 
Excessive and inappropriate drinking6 is harmful not only to the individual but also to the people 
around him or her. 
Alcohol misuse is associated with social and mental health problems including domestic violence, 
crime, occupational and road accidents, depression and suicide. Misuse is more common in certain 
occupations, including people in the hotel trade, entertainment, journalism and the armed forces. 
Heavy drinking can cause liver cirrhosis, and levels of cirrhosis deaths in a country are a 
population indicator of alcohol misuse. Sustained heavy drinking progressively increases the risk of 
raised blood pressure and stroke and possibly coronary heart disease. 
As far as alcohol consumption is concerned, the trend (see Fig. 4.1.4) shows a decrease in the sales 
of alcohol in the mainly wine-drinking southern EC countries and an increase in the mainly beer-
drinking northern countries. There is reason to believe that part of the explanation for this development 
is a change in consumption patterns, which has resulted in a marked rise in wine consumption in 
northern Europe and a decrease in the south. 
Fig. 4.1.5 shows the large differences in excise taxes on spirits in Member States and there are 
equally wide ranges for table wine and beer. 
Some Member States have published guidelines on levels of weekly alcohol consumption in relation to 
health risk. 
1"> 
Some recent Community directives on alcohol relate to: 
* television advertising (1989) 
* driving licences not be issued to applicants dependent on alcohol ( 1991 ) 
* minimum rates of excise tax on alcoholic beverages ( 1992). 
Drug misuse 
Despite customs and police action, illegal drugs are a growing problem in the Community. Seizures 
of heroin in the Community' rose from 1.9 tonnes in 1987 to 5.2 tonnes in 1992. Cocaine powder 
seizures rose from 3.5 tones to 17 tonnes over the same period. 
There are estimated to be up to one million people using illegal drugs in the Community: the true 
picture is not clear because countries have different laws about drug misuse and different reporting 
systems. A recent national survey in France recorded that over 30% of men and 10% of women aged 
18-34 had used drugs (mainly cannabis) at some time in their lives, and half of this group had done 
so during the previous year. In Spain in 1988, 36% of 18 year-old males reported having used cannabis 
and 3% cocaine. 
Opiate and cocaine misusers are more often men than women. Crime, especially burglary and 
prostitution, may be used to pay the costs of addiction. 
Some countries record the number of people attending treatment programmes, but only a minority 
of drug misusers are in regular treatment. Deaths from drug misuse, probably accounting for 1-2% 
of regular opiate users, rose steeply in the late 1980s (Fig. 4.1.6). 
The Commission has adopted an integrated action plan for 1995-1999 to combat drugs. This 
proposes action: 
* on demand reduction through prevention, including health education and social 
reintegration: 
* to combat illicit trafficking, including cooperation between police, customs and judicial 
systems, training and exchange; 
* to increase international cooperation and coordination; 
* to obtain better quality information concerning drugs and drug addiction and improve 
information f ows through the European Monitoring Centre för Drugs and Drug Addiction 
in Lisbon. 
Nutrition 
Most nutritional problems now are related to eating too much or the wrong balance of food, leading 
to obesity. Germany (West), Ireland and the United Kingdom show high levels of obesity in men and 
women (Fig. 4.1.7), though the differences between countries may be influenced by different methods 
of data collection. 
23 
No svstematic surveys of eating patterns in the Community have yet been published. However, 
economic data are available about food products. These are based on the balance between home 
production, imports and exports, and so only roughly reflect what is actually eaten. Since the 1970s 
there appear to have been significant changes of consumption in EC countries: there are also marked, 
and continuing, differences between northern and southern EC countries (grouped in Fig. 4.1.8 as eight 
northern countries, with Greece. Italy. Portugal and Spain, representing southern countries). 
* Animal fats: consumption is high and steady in northern countries, while it is low, but rising, in 
the south. 
* Sugar: consumption in northern countries is high but falling whereas in southern countries it is low 
and is more or less unchanged. 
* Vegetables and fruits: consumption increased in all countries in the 1980s but remains considerably 
lower in northern than southern countries: 
* Cereals and cereal products: there is .a falling trend in southern countries and a low. but rising 
(since the early 1980s) consumption in northern countries; 
* Oils: there has been a substantial increase in the use of oils containing polyunsaturated fatty acids 
in southern countries. Since the mid 1970s, the rates in southern countries have increased beyond 
those in the north. Olive oil continues to be consumed mainly in southern countries. 
The traditional Mediterranean diet, eaten in Greece, southern Italy, southern France and parts of 
Portugal and Spain, when accompanied by regular physical activity, appears to be associated with long 
life expectancy. This diet is of vegetable origin, including bread, pasta or rice, fresh fruit and 
vegetables, pulses and legumes, olives and olive oil. Cheese and other dairy products, and fish, poultry 
or eggs are consumed on most days, but red meat is eaten only a few times a month. In contrast, 
northern European diets, high in animal products, have been associated with poorer life expectancy, 
and especially with coronary heart disease. 
Several EC countries have made proposals for changing national diets by: reducing the energy 
derived from, and the proportion of. saturated (especially animal) fats; decreasing sugar intake and 
increasing that of other carbohydrates (for example, cereals) according to energy needs; increasing the 
amount of fibre (from cereals, vegetables and fruit); and balancing nutrient intake with needs. 
However, transferring these population recommendations to individuals is difficult. 
Few people are aware of the nutrient content of their meals, and eating is a very strongly ingrained 
area of cultural behaviour. Health education is needed to develop knowledge and attitudes, but healthy 
choices must also be supported by policies and actions of other sectors in relation to the food available 
to the consumer. 
Exercise 
Physical fitness contributes to good health. Exercise, either at work or in leisure, reduces death rates 
from both heart disease and cancer, and can also increase mental wellbeing. Even moderate 
improvements in fitness have important effects. 
BLAIR. S.N. ET AL. Physical fitness and all-cause mortality. Journal of the American Medical 
Association. 262(17): 2395-2401 (1989). 
24 
For the elderly, exercise within the limits of their physical capacity and on the advice of their 
physician can reduce symptoms of heart disease, reduce bone loss associated with aging and increase 
muscle mass and strength. It can also improve mental functioning and contribute to an overall sense 
of wellbeing. Simple walking done regularly, especially with companions, may be all the exercise that 
is needed. 
Physical activity needs to be done regularly to strengthen the heart and lungs. This is possible in 
some manual occupations, but may need to be paid special attention by other people. 
For most people, walking, rather than a sport, provides the most frequent exercise. Health surveys 
show that a substantial proportion of young adults play sport regularly, but the numbers fall off rapidly 
over the age of 30. Work and domestic commitments may in part explain this. 
4.2 The environment and health 
There is as yet insufficient clear-cut information on the harmful effects to humans from environmental 
hazards, and where the exact effects are not known, especially of low levels of exposure, only broad 
estimates of the risks for large populations can be made. 
The relative contribution of environmental hazards to disease is generally small, but damage to the 
environment may be irreversible and exposure can lead to health effects over many years. The 
environment may particularly affect the health of some groups of the population, such as children, 
pregnant women or people with existing illnesses, more than others; and effects showing as deaths may 
be only part of the full impact. Some environment-related diseases are shown in Fig. 4.2.1. 
The World Health Organization and the European Commission are collaborating to investigate 
the risks of environmental damage. A report of the major conference. "Second European 
Conference on Environment and Health" held in June 1994 in Helsinki, is forthcoming. A pan-
European state of the environment report "Europe's environment: the Dobris assessment", 
together with a Statistical Compendium, have been prepared by the Commission in collaboration 
with international organisations and national focal points. These give an overview of 
environmental problems, including health and environment. 
Housing 
A minimum component of good housing is having basic sanitary facilities - an inside lavatory and bath 
or shower. The data available, which should be interpreted cautiously because of differing methods of 
definition and collection, suggest that in 1985 no EC country had achieved this standard in all its 
housing. About 20 million people live without an inside lavatory and 30 million without an inside bath 
or shower. Using a rather broader definition, about 28 million housing units, accommodating 71 million 
people, are estimated not to reach national criteria of good quality (Fig. 4.2.2). 
25 
People, especially in northern countries, are inside buildings most of the time. Central heating in 
northern climates, with fewer coal fires, has helped reduce some children's respiratory illnesses. 
However more insulation and less ventilation, to keep houses warm, creates higher humidity and may 
lead to an increase in house dust mites and fungal spores, which cause allergy and asthma. Tobacco 
smoke in enclosed rooms is a risk for lung cancer through passive smoking: it is also a health risk for 
children in daytime indoor environments, increasing problems with respirator) and middle ear 
infections and with bronchitis and asthma. 
Data available for housing in Germany shows that, compared to the western Lander, housing units 
in the eastern Lander are smaller and their rents have risen sharply (Fig. 4.2.3). 
Homelessness 
In the Community in 1994. nearly 2.5 million people were estimated to be without shelter or living 
in temporary accommodation. The highest rates were estimated to be in France. German} and the 
United Kingdom (Fig. 4.2.4). but there may be underrecording in some EC countries. There are also 
the "hidden homeless", for example people staying with a friend, in a hotel or a guest house, or those 
soon to be released from institutions (prisons, mental hospitals), bringing estimates of all homeless 
people to 5 million. There are many reasons for homelessness. but men are more likely to be without 
housing for financial reasons and because of problems of dependency, while women are more likely 
to be homeless through relationship problems, especially domestic violence. 
Homeless people experience greater stress and poorer health, especially chronic illnesses, than the 
general population. Overcrowding in temporary accommodation can cause stress and encourage the 
transmission of infectious diseases, for example tuberculosis in migrant families and infectious hepatitis 
in centres for refugees. Homeless people without shelter are exposed to respiratory illnesses (including 
pneumonia), hypothermia, accidents and violence. 
Transport 
Transport can promote health through exercise (e.g. bicycling), and through access to employment, 
shops, social networks, recreation and countryside. Transport can, however, also adversely affect health 
through, for example, accidents and environmental pollution. 
Transport accident, death or injury rates do not directly measure safety, as they also depend on 
exposure. For example, there has been a decreasing rate of children injured on the roads in Britain, but 
the proportion of 7-year-old children allowed to go to school unaccompanied fell from 70% in 1971 
to 10% in 19908. Walking and cycling, even for short distances, are, however, healthy forms of 
transport that reduce heart disease (Fig. 4.2.7) and promote mental health. Their use should be 
encouraged and supported through better safety and other measures. 
HlLLMAN. M.. ED. Children, transport and the quality of life. London, Policy Studies Insitute, 1993: 
Fieure 2. 
26 
Access 
Up to 15% of the population - 50 million people - have some form of temporary or permanent 
reduction in their mobility' owing to physical disabilities, such as locomotor, chest and heart problems. 
sensory impairment such as partial sight, or mobility constraints such as people with push-chairs. The 
majority affected are older people. Their special transport needs include access to public transport 
vehicles and buildings, "dial-a-ride" schemes, and pavement improvements. The demand can only rise 
and this will require an appropriate response to prevent social exclusion and all its consequences. 
Noise 
A number of studies have been made on noise and health. Apart from inducing hearing impairment, 
noise can interfere with communication, lead to sleep disturbance and provoke stress and annoyance. 
A survey in Germany showed that road traffic is a predominant source of disturbance, with 20% of 
people seriously disturbed by traffic noise (Fig. 4.2.5). A EUROBAROMETER survey shows that 
urban car traffic noise adversely affects more than half the population in most Member States (Fig. 
4.2.6). 
Air 
The replacement of coal by other fuels in domestic heating and energy production has resulted in a 
steady decline in levels of smoke and sulphur dioxide in urban air. In spite of these reductions, concern 
about the effects of exposure to particulates has increased with the recent publication of studies 
indicating that exposure to small particles, at levels currently experienced in many European cities, is 
associated with changes in morbidity and mortality'. Figs 4.2.8a and 4.2.8b show particle levels as 
measured in large cities in the Community. In urban areas a major source of particulate pollution is 
traffic. Other traffic related pollutants currently of concern include photochemical smog in the summer, 
in particular ozone, exposure to which has been associated with irritation of the eyes and increased 
asthmatic symptoms. Winter smog has been associated with bronchitis and asthma. Exposure to low 
levels of lead from traffic fumes has been associated with impaired intellectual development in 
children, and products of incomplete combustion may contribute to lung cancer in adults. Deposition 
of heavy metals and compounds such as dioxins on soils, and directly on crops and vegetables has been 
identified as a possible route by which human health may be affected. 
Water 
As a result of good engineering control, drinking-water supplies in the Community now do not usually 
contain harmful concentrations of bacteria or viruses. However, agricultural fertilizers and pesticides, 
which are hazards to health, are entering groundwater and thus drinking-water, causing concern about 
potential risks of diseases such as cancers or birth defects. 
Waste and sewage 
The Community' produces 2000 million tonnes of industrial waste, which is either put in landfills or 
incinerated; 1% of this is toxic and hazardous waste, but it accounts for 20% of all costs of treatment. 
Combustion of solid waste contributes to air pollution. An overall reduction of waste would reduce 
these risks. Discharge of untreated sewage into rivers and the sea can both make sea-bathing dangerous 
and contaminate fish through the food chain. 
27 
Radiation 
Ultraviolet radiation from sunlight is an important cause of skin cancers, accelerates the development 
of cataracts and impairs immunocompetence. Behaviour is an important determinant of exposure to 
ultraviolet radiation and education has a role in reducing the exposure of the population. Exposure to 
ionizing radiation can cause leukaemia and other cancers. There are well-recognized arrangements to 
protect people from radiation in industry: use of medical X-rays, an important source of exposure for 
the population, should be optimised. Radon in buildings arises primarily from ingress from the 
underlying soil, but also from some building materials; however, exposure can be limited by a number 
of measures. 
Biodiversity' 
The conservation and sustainable use of biological and genetic resources in the Community and 
worldwide is particularly important to the development of future medicinal products. 
4.3 Social concerns 
Unemployment 
The relationship between unemployment and health is complex. Sudden redundancy and long-term 
unemployment can create stress with consequent psychological problems. Unemployment in the 
Community fell from 10.8% in 1985 to 8.3% in 1990. However, this gain was lost in the recession of 
1992/1993 (Fig. 4.3.1). In many areas of the Community, especially those in Greece, Ireland, Portugal 
and Spain (see Fig. 4.3.2) more than 20%. and at times more than 40%, of the unemployed are young 
people. About 5 million new jobs need to be created by 2000 to keep unemployment in the Community 
at current levels, and 15 million new jobs would be needed to bring unemployment down to 5-6%. 
The European Commission has published a White Paper on proposals for achieving faster 
economic growth, including employment skill trainging and new job creation. The 'caring 
services", including health and social services, are identified as an area of potential employment 
growth, offering flexibility in working hours, opportunities for women and solidarity between 
generations. 
Poverty 
Poverty' describes the position of people who are significantly worse off than the average for the 
society. On average, poor people are less healthy than rich people (section 2.3). Children in families 
where there is insufficient support have more emotional disorders. Accidents and violence, heart 
disease, most cancers and dental caries are more common in poor people. Groups with low incomes 
include single-parent families, the long-term unemployed, migrants and elderly people living alone. 
28 
One definition of poverty sometimes used is the percentage of the population whose household 
expenditure is less than 50% of the average. Fig. 4.3.3 shows two approaches using this definition of 
poverty, based on data taken from national surveys. The first method compares household expenditure 
to the countty 's own average ( 18% of the UK's population has an expenditure which is 50% or less 
than the average household expenditure in the United Kingdom compared with 6% of the population 
of Belgium). The second method compares expenditure against the Community average, emphasizing 
the comparatively lower national expenditure levels of Greece. Ireland. Portugal and Spain. By both 
methods Belgium. Denmark. Germany and the Netherlands appear to have less "poverty" than other 
countries. 
4.4 Health services 
Health services contribute to improving health both after the onset of disease and through prevention. 
Health services cure some conditions - for example, treatment of bacterial infections with antibiotics 
and some surgical operations - and provide palliative and supportive care for chronic conditions such 
as arthritis, heart disease, chronic mental illnesses and many cancers. 
Country health systems 
Health services have an important place in national economies. In EC countries, they consume between 
5 and 9% of gross national product (10 to 15% of public expenditure), and across the Community they 
employ more than 6.5 million people. All countries are experiencing pressure for more expenditure, 
due to the greater needs of aging populations, medical advances, the need for prevention and rising 
expectations regarding the quality of care. 
Although the health services are all seeking to achieve the same ends, each country's is different, 
because of its historical and political development. There are two basic patterns. Five countries - -
Belgium, France. Germany. Luxembourg and the Netherlands - have pluralist systems, with services 
from both private (usually non-profit) and public organizations financed mainly from compulsory 
health insurance. Seven countries - Denmark. Ireland, Greece, Italy, Portugal, Spain and the United 
Kingdom - have national health services in which provision and financing is mainly within the public 
sector. 
Within these broad categories there is considerable diversity in terms of methods of organisation, 
financing and ideology, which make comparisons more difficult. The Netherlands has a mix of public 
and private insurance, while in France most health insurance is controlled by the state and in Germany 
there is a large number of occupation-related insurance funds. The United Kingdom health service is 
managed through specific health authorities, while in Denmark it is controlled mainly by county' 
administrations. General practitioners usually refer patients to specialists in Denmark, Germany, 
Ireland, Italy, Portugal, Spain, and the United Kingdom, but in other countries patients have direct 
access either to generalists or specialists. The methods of remuneration for medical practitioners (fee -
for - service, capitation fee, salary) also differ widely. Public health services, oriented towards the 
population as a whole rather than individual clinical practice, are at various stages of development in 
different countries. 
29 
Several countries are currently seeking to reform their health services, to improve both the 
efficiency (including cost-containment) and the effectiveness (including quality of care and 
inequalities). For example: 
* A review of health insurance was made in the Netherlands in 1986. The main concern was to 
ensure equitable cover for basic health care through either public or private insurance, and to 
extend market principles. A national Strategy for Health was published in 1992. 
* Changes in the German health system in 1989 and 1991 have included co-payments for drugs, 
pavment of general practitioners for preventive care, rationalization of hospitals and improvements 
in the quality of medical practice, as well as increasing finance for long-term care. 
* The United Kingdom has seen major reforms since 1991 : payment to general practitioners oriented 
towards targets for preventive care; and local budgets for health authorities and general practitioners 
to buy health services in an "internal market" of health care providers. Also, across the country, 
there have been parallel efforts to develop long-term health strategies with specific health targets. 
* Greece. Italy. Portugal and Spain all reformed their health services in the 1970s and 1980s. While 
finance is primarily through the public sector, each country retains a mix of private as well as 
public provision, and there is decentralization of planning to regions. 
* Ireland is strengthening general practitioner and community-based services. Its national health 
strategy, published in 1994, seeks a greater focusing of services towards measured health gain and 
social gain, and sets specific targets. 
Health promotion and disease prevention 
Health services are increasingly engaging in health promotion and disease prevention. Ministries of 
Health in several Member States have developed national policies in these areas. Some Member States 
have specific health promotion budgets at national level, while all include health education within local 
public health programmes. Intersectoral initiatives, also at local level, are increasingly being developed. 
There are three broad fields of public disease prevention programmes: acute infectious disease 
surveillance and control; child health, especially vaccination: and screening programmes, for example 
for cervical cancer. Providers of these services may either be employed within the public authority's 
services or be privately contracted practitioners. However, in contrast to individual clinical practice, 
where a patient voluntarily consults a doctor, preventive services need overall management by the local 
public health service to ensure population coverage and effectiveness. 
General practitioners are playing an increasing role in individual preventive medicine for adults. 
Some of this is primary prevention, such as advice on contraception, stopping smoking, reducing 
alcohol intake and improving diet; some is secondary prevention, for example cervical cytology and 
blood pressure screening; and some is tertiary prevention (early diagnosis and management of 
depression). Effective management of prevention in primary care needs good information systems, 
usually computer-based, to ensure coverage and recall of all patients served. In the United Kingdom 
general practitioners are now being paid for achieving target levels of prevention for their patients. 
30 
Patterns of care 
The broad structure of medical practice is the same in all countries. Primary care is the usual level of 
first contact for a patient. Because of the mixed nature of many illnesses, primary care is increasingly 
provided by teams including doctors, nurses and other health staff. Secondary care is mainly provided 
in general hospitals or clinics, where specialists can work together and share nursing, laboratory and 
imaging facilities. There is an increasing move to integrate specialist mental health care in general 
hospitals, to coordinate provision with community care, and to close large, separate mental institutions. 
Highly specialized hospitals are often associated with universities for research and training. 
Staff 
Numbers of professional staff are increasing. Between 1980 and 1990, the total number of nurses in 
the Community' countries rose from 1.2 million to 1.5 million. For doctors, general practitioners 
increased from 0.78 to 1.03 per 1000 population in France, from 1.0 to 1.2 in Germany and from 0.48 
to 0.57 in the United Kingdom. Numbers of specialists increased even more over the same period -
from 0.6 to 1.2 per 1000 in France and from 1.0 to 1.6 in Germany. However, an upward trend in the 
proportion of expenditure on hospitals in the 1970s, rising for the Community' from 43% in 1970 to 
49% in 1980, was reversed down to 46% by 1990. Only Greece has seen a significant further rise, 
from 49% in 1980 to 57% in 1990. 
Hospital use 
There are substantial differences between countries in the provision and use of acute hospitals (the data 
should be interpreted with caution because of variations in definitions between countries). There has 
been a downward trend in the provision of hospital beds for acute (short- rather than long-term) care. 
For example, in Ireland several hospitals were closed, with a fall between 1980 and 1990 from 5.4 
to 3.5 acute beds per 1000 population, while in France provision fell from 5.8 to 5.0 over the same 
period. However, there are continuing differences between countries in acute bed provision: in 1990 
there were 7.5 beds per 1000 in Germany, 5.0 in France and 2.8 in the United Kingdom. 
At the same time, there has been increasing in-patient admissions. Between 1980 to 1990 the 
percentage of the population admitted to hospital increased from 17.5 to 21.0 in France and from 16.3 
to 18.5 in Germany. Similarly, average patient days per admission fell from 9.9 to 7.0 days in France 
and 14.9 to 13.4 in Germany over the same period. 
Pharmaceuticals 
Member States are both producers and consumers of pharmaceuticals. The number of drugs available 
for prescription, and their relative price (Fig. 4.4.1), varies between different EC countries. Differences 
between countries are the result of national regulations on pharmaceutical retailing, price control 
mechanisms and the product pricing structures of pharmaceutical companies. 
About one new drug in four is made using biotechnology, and this market is likely to increase. 
Only 15% of all biotechnology patents are European, and there is a need to develop research in this 
area. The areas of authorizing new pharmaceuticals before marketing and recording adverse reactions 
are to be the concerns of the new European Agency for Evaluation of Medicinal Products sited in 
London. 
31 
Quality 
Two assessments of the effectiveness of health care have been made from research sponsored by the 
EC: 
* An atlas of 'avoidable death' (2) compares countries using standardized mortality ratios from 
selected conditions amenable to medical or surgical intervention. lor example, deaths from 
appendicitis by the 451 adminstrative areas of the EC are shown in Fig. 4.4.2. However, it is 
difficult to draw conclusions on the quality of care from these data, as there may also be variations 
in both the incidence and the recording of these conditions. 
* A study of colon cancer survival, using cancer registers in EC countries, showed significant 
variations in the Community (Fig. 4.4.3). Data are based on hospital diagnoses reported to cancer 
registers. However, there remain difficulties in comparing survival because of variations in the 
completeness of the data, methods of follow-up, etc. Further information on treatment given, for 
example to individual patients within defined populations, will help understand these variations. 
Improvements in recent years in mental health services include more mental health care being 
provided in local .settings by multidisciplinary teams, with support from general practitioners. As a 
result, patients are being admitted to hospital for shorter periods and the number of psychiatric hospital 
beds is being reduced in most countries (Fig. 4.4.4). 
Older people are higher users of hospital services than younger people. Integrated services, with 
good communication between hospitals and primary care teams, can contribute effectively to reducing 
many problems of aging, and to limiting the need for residential care. 
Research 
Most EC countries have a longstanding tradition of medical research. The EC funds research through 
programmes on Research and Technological Development. Six programmes of medical research have 
been funded since 1978. and the success of the strategy is indicated by the rapid increase in partici­
pating teams (Fig. 4.4.5). 
The biomedical and health research programmes cover a wide range of basic and applied topics. 
Epidemiological and health services research has been supported, but the largest proportion has gone 
to basic science and laboratory research. With the new public health responsibilities of the EC, there 
is a need to support population-based research in these areas, such as the development of information 
systems and studies evaluating public health interventions for major health problems. 
A significant amount of research relevant to health has also been carried out in the framework of the 
Community's environmental research programmes. 
The Telematics Application and the AIM (Advanced Informatics in Medicine) programme (1991 
to 1994). brought together industry, telecommunication service poviders. academic research and 
health care professionals in Member States. Actions to date include: 
* telematic tools for transmitting laboratory information 
* telematic transfer of microscope images 
* a network of national bone marrow donor banks 
* data cards for the care of patients with diabetes 
* telematic exchange of health and health care data between Member States 
* teiemedicine 
* a multilingual computerized drug prescription system. 
Chapter summary 
In addition to health-related behaviour, the environment and social life are important determinants of 
health. Improvement of the external environment - air, water, waste, radiation - contributes to health; 
transport, especially motor vehicles, can be a health risk. Health services are being reformed in many 
countries, mainly to improve cost control, and need to include public health within their objectives. 
References 
1 HOLLAND, W.W., ED. European Community atlas of 'avoidable death ' (2nd edn.). Oxford, Oxford 
University Press, 1991. 
33 
Chapter 5 
Towards a healthier Europe 
This report has described the main health issues facing the European Community. While most children 
are healthy, young adults are particularly affected by accidents. Important health problems of middle 
age include cardiovascular diseases and cancer. Older people are the largest group with disabilities. The 
determinants of ill health have also been described. The main addictions - tobacco, alcohol and drugs -
are closely associated with the main health problems. Aspects of the environment, social behaviour 
and health services have also been considered. 
The report has also illustrated that life expectancy in the Member States of the Community is 
among the highest in the world, although other countries have shown impressive improvements, in 
some cases outranking countries of the Community. 
It is in this context that two important and linked questions arise: is it feasible to expect further 
improvements in life expectancy in the Community, and from which age and disease groups are such 
improvements most likely to come? 
Present knowledge about the biological limits on human longevity is insufficient to give any 
definitive answer to these questions. But a simple comparison of past mortality trends and theoretical 
limits (when mortality rs completely eliminated by main causes of death or age groups) can give an 
indication of potential for further improvements. This allows the identification of priorities, as well as 
of areas where improvement in health status can be obtained. 
During the past two decades, average infant mortality has decreased significantly in the Community, 
resulting in an increase in life expectancy of more than one year or 25% of the total increase. 
However, because of the already low levels, potential for further improvements is very limited. Even 
if infant mortality was completely eliminated (which, of course, is impossible) the maximum gain in 
life expectancy would be only 0.6 years. The elimination of all mortality in the age group 1-34 would 
give an increase of about 1.2 years, while in the age groups 35-64 and 65-74 it would yield an increase 
of about 4.1 and 3.3 years respectively. The elimination of each of the major causes of mortality in 
the age group 0-74 (i.e. cardiovascular diseases, cancer and external causes) would provide about 2.3, 
2.7 and 1.2 years of increase in life expectancy respectively. Given the above estimates, it becomes 
clear that the main potential for improvements in life expectancy are to be found in tackling the three 
leading causes of death in middle ages. A 50% reduction in these causes would give an increase of 
about 3 years. With the present average annual increase in life expectancy of 0.2 years it would take 
about 15 years to achieve this. 
On this basis three main conclusions can be drawn: 
1. At present, the main potentials for increasing life expectancy lie in reducing mortality in young 
and middle-aged people from cancer, cardiovascular diseases and external causes of injury and 
poisoning. 
Once the potential for improvement in premature mortality' has been exhausted, it would be 
expected that the present increasing trends in life expectancy would start to slow down. 
34 

3. In the not too distant future, increases of life expectancy could come through gaining some 
influence on the aging process, but with such an extension of life, diseases of the elderly could 
become more prominent. 
It is against this background that the trends in the main addictions considered in this report, 
especially among young people, are of particular concern. If the main gains in life expectancy are to 
come from a reduction of cardiovascular diseases, cancers and accidents in the age groups 35-64 then 
steps must be taken to influence current trends in health-related behaviour. 
These require action by all the sectors that could influence such health behaviour and should 
comprise three elements: first, intersectoral action to promote health. Measures should aim at 
influencing behaviour through education and information and at facilitating and enhancing healthy 
lifestyles. Second, actions aimed at improving the quality of life, such as by reducing social exclusion 
promoting solidarity, and by taking measures based upon sound scientific research to improve the 
environment. Third, actions to develop public health, such as improving the accuracy and 
comprehensiveness of health data and strengthening of prevention and promotion measures by the 
health services. 
35 
Annex 1 
Notes and glossary 
This report describes the 12 countries that constituted the European Union in 1994. Data available since 
1970 for all countries have been included where possible. For the period before the unification of 
Germany in October 1990, information generally is for west Germany, and from 1991 it includes east 
Germany. 
The information comes from many sources. The main ones are the data provided by the Member States 
to the World Health Organization's Regional Office for Europe and contained in its Health for All 
database and country monitoring reports; publications issued by the European Commission, including 
EUROSTAT: specialist sources within other international and nongovernmental organizations: and 
scientific publications. 
Wherever possible, data for all 12 member countries are shown. In line graphs this may reduce the 
readability - especially in the case of infrequent events and/or small populations. For this reason, 
annual trend data for Luxembourg are usually represented as smoothed 3-year moving averages. 
Mortality data 
Although this report is concerned with health, much of it is based on evidence of mortality given 
available data. Reduction of premature mortality and its determinants is. nevertheless, an important 
component of improved health. 
Data on deaths are from death certificates, which are completed by doctors and are legal documents. 
The cause of death written on the certificate is coded by internationally agreed procedures but may 
underestimate the presence of some diseases, especially if there has not been a pathological 
examination after death, which is more often the case for older people. However, these shortcomings 
are relatively steady over time, allowing more confidence in trends. 
When presenting data on deaths in this report, the actual number is sometimes given, to emphasize the 
total. More often, however, standardized death rates (SDRs). are used as these take into account the 
age structure of different populations and allow more meaningful comparisons. 
Glossary of selected terms 
Incidence: the rate of occurrence of new cases of a disease in a population during a period 
(usually a year). 
Prevalence: the number of existing cases of a disease in a population at a given time or period. 
Standardized death rate (SDR): 
deaths (usually per 100 000) adjusted to the age structure of a standard European 
population. (See World Health Statistics Annual 1993. Geneva, World Health 
Organization 1994: p. XXXIV.) 
36 
Standardized mortality ratio (SMR): 
the ratio (multiplied by 100) of deaths in the study population or subgroup to the 
number that would be expected if the studs population had the same specific rates as 
the reference population. Populations or subgroups with SMRs greater than 100 are 
less healths, and less than 100 more healths, than the comparison population. 
Perinatal mortality rate: 
the number of children stillborn and dying within the first week of birth per 1000 still 
and live births. 
Infant mortality' rate: 
the yearly number of deaths of children aged less than one year per 1000 live births. 
Total fertility' rate: 
the average number of children that would be born alive to a woman during her 
lifetime, if she were to bear children at each age in accord with prevailing age-specific 
rates. 
Annex 2 
List of figures 
Fig. 1.1 
Life expectancy at birth in IX countries and heights of Dutch recruits. 1950-1090 
Fig. 1.2.1 
Self-perceived health in selected EC countries. 1990-1991 
Fig. 2.0.1 
Population (in thousands), EC countries. 1993 
Fig. 2.1.1 
Population age structure in EC. 1970 and 1993. males and females 
Fig. 2.1.2 
Trends in total fertility rates. 1960-1990 
Fig. 2.2.1 
Life expectancy at birth, total population. 1970-1992 
Fig. 2.2.2 
Life expectancy at birth and real GDP around 1991. in selected countries 
Fig. 2.2.3 
Life expectancy in developed market-economy countries: changes in rank between 1970/1971 and 
1991/1992 
Fig. 2.2.4 
Age-specific total mortality: Community average and best in Europe, 1990 
Fig. 2.3.1 
Changes in male/female death ratios in France between 1920-1924 and 1985-1989. 
Fig. 2.3.2 
Average age of insured population of males at death, Germany, 1975-1985 
Fig. 2.3.3 
Standardized mortality ratios by social class, males of working age under 65, United Kingdom, 1951-
1981 
Fig. 2.3.4 
All-causes mortality, all ages, standardized mortality ratios, by administrative areas, EC, 1980/1984 
Fig. 3.U.J 
Main causes of death; profile by age, EC. 1991 
38 
Fig. 3.0.2 
Distribution of total deaths by cause, age and sex. EC. 190) 
Fig. 3.1.1 
Infant mortality rates in EC. 1970-1992 
Fig. 3.1.2 
Prevalence per million population of haemoglobin disorders. EC countries. 1092 
Fig. 3.1.3 
DMFT index for 12 year-olds. 1980 and 1990 
Fig. 3.1.4 
Measles incidence in selected countries. 1980-1993 
Fig. 3.2.1 
Adolescents. 15 year-olds' behaviour in selected countries. 1990 
Fig. 3.2.2 
Daily smokers in selected countries, females at ages 11.13 and 15 years. 1990 
Fig. 3.2.3 
Live births per 1000 women aged 15-19. 1980 and 1990 
Fig. 3.2.4 
Road deaths in the United Kingdom by neans of transportation. 1992 
Fig. 3.2.5 
Trends in road traffic deaths, age-standardized death rates, all ages, 1970-1992 
Fig. 3.2.6 
Change in road traffic deaths and injuries. 1985-1992 
Fig. 3.2.' 
Trends in homicide rates in males aged 20-34 years 
Fig. 3.3.1 
Distribution of main cancers in men and women by site. Italy and the United Kingdom, 1983-1987 
Fig. 3.3.2 
Trends in male lung cancer deaths, age-standardized death rates, age 0-64 years, 1970-1992 
Fig. 3.3.3 
Trends in female lung cancer deaths, age-standardized death rates, age 0-64 years, 1970-1992 
Fig. 3.3.4 
Breast cancer annual incidence in registries of selected EC countries, 1970 and 1985 
Fig. 3.3.5 
Male mortality from stomach cancer, age-standardized death rates, all ages, in selected EC countries, 
1970-1974 and 1985-1989 
39 
Fig. 3.3.6 
Trends in mortalin from coronary heart disease, age-standardized death rates, age 0-64 years. 1970-
1092 
Fig. 3.3.' 
Risk factors in men in ~ EC regions 
Fig. 3.3. S 
Heart attack rates by sex. age 35 to 64. 7 EC regions 
Fig. 3.3.9 
Trends in mortality from cerebrovascular diseases, age-standardized death rates, age 0-64 years. 1970-
1992 
Fig. 3.3.10 
Trends in mortality by liver diseases and cirrhosis, age-standardized death rates, age 0-64 years. 1970-
1992 
Fig. 3.3.11 
Estimated prevalence of some chronic diseases (from a variety of localized studies) 
Fig. 3.3.12 
Occupational accident death rates per million population and total number of fatal accidents. 1992 
Fig. 3.3.13 
New cases of permanent disability recorded by social insurance in France and Germany, per year, per 
1000 employees. 1986. 1987 
Fig. 3.3.14 
Trends in incidence of AIDS. 1981-1993 
Fig. 3.3.15 
Cumulative AIDS cases (adults/adolescents) by country and transmission group (December 1994) 
Fig. 3.3.16 
Tuberculosis, rates of annual notification. EC average and selected countries, 1974-1993 
Fig. 3.3. r 
Trends in mortality by suicide and self-inflicted injury, all ages, 1970-1992 
Fig. 3.3. IS 
Parasuicide rates in towns of five EC towns and regions, 1989 
Fig. 3.4.1 
Trends in life expectancy at age 65, 1970-1992 
Fig. 4.1.1 
Percentage of adult population (15+) who are regular smokers, 1991-1992 
Fig. 4.1.2 
Percentage of smokers wishing or trying to stop, 1993 
40 
Fig. 4.1.3 
Relative price index of 20 cigarettes (popular brand) in LC countries. 1002 
Fig. 4.1.4 
Annual alcohol consumption in litres per person. 1070 and 1090 
Fig. 4.1.5 
Excise taxes on spirits (100% alcohol) in EC countries. 1992 
Fig. 4.1.6 
Trends in deaths from overdose of illicit drugs, crude death rates, selected EC countries. 1980-1003 
Fig. 4.1.' 
Percentage of adult population very overweight, selected EC countries, around 1990 
Fig. 4.1.8 
Changing patterns of food consumption in the EC. 1970-1990 
Fig. 4.2.1 
Environment-related diseases 
Fig. 4.2.2 
Households lacking sanitary facilities in the EC. 1985 
Fig. 4.2.3 
Housing in Germany, western and eastern Lander. 1987-1991 
Fig. 4.2.4 
Estimated homelessness per 1000 inhabitants in the EC. 1991-1992 
Fig. 4.2.5 
Percentage of population disturbed by noise. Germany. 1987 
Fig. 4.2.6 
Effects of urban car traffic, 1991 
Fig. 4.2.-7 
Heart attack rates in cyclists and non-cyclists, males. United Kingdom, 1976-1986 
Fig. 4.2.Ha 
Total suspended black smoke concentrations in selected EC cities, average over 1986-1991 
Fig. 4.2.8b 
Total suspended particulates in selected EC cities, average over 1986-1991 
Fig. 4.3.1 
Unemployment levels in the EC. Japan and USA 
Fig. 4.3.2 
Percentage of unemployed under 25 years of age. EC. 1992 
41 
Fig. 4.3.3 
Per cent of the population with household expenditure less than half of the national average and EC 
average household expenditure. 1985 
Fig. 4.4.1 
Relative price index of pharmaceuticals. 1993 
Fig. 4.4.2 
Standardized mortality ratios for appendicitis, ages 5-64 years. EC. 1980/1984 
Fig. 4.4.3 
Variation in survival (%) for colon cancer, from cancer registries in 7 EC countries. 1978-1985 
Fig. 4.4.4 
Psychiatric hospitals - beds per 1000 population. 1980 and 1989 
Fig. 4.4.5 
Biomedical and health research programmes, EC, 1978-1994 
42 
in years 
80-
70-
Denmark 
60-
1950 1960 1970 1980 1990 
Tji Height of Dutch recruits 
Life expectancy at birth. EC 
Source: United Nations. World Population Prospects. 
The 1992 Revision. New York. 1993 and 
Floud R.. Measuring European inequality: 
the use of height data. 
Fig. 1.1. Life expectancy at birth in EC countries 
and heights of Dutch recruits, 1950-1990 U.Kingdom 
0 20 40 60 80 100 
Per cent 
| H Poor/very poor Q| Very good/good 
Source: WHO/EURO: Health for All 
country monitonng reports. 
Fig. 1,2.1. Self-perceived health 
in selected EC countries, 1990-1991 
Source: EUROSTAT-Demographc statistics 1994 
Luxembourg. 1994. 
Fig. 2.0.1. Population (in thousands), EC countries, 1993 
43 
Age 
95-99 90-94 65-89 80-84 75-79 70-74 65-69 60-64 55-59 50-54 45-49 40-44 35-39 30-34 25-29 20-24 15-19 10-14 5-9 0-4 MALES JÏ-- FEMALES 
rr11 I"1] 
n -.-* n 
,,.'''-'• : •' • y 
.'.'• ••••• : • •/',, 
1 
, n . I 1—; I i -J I 
10 8 8 10 
% of population 
; Z2 1970 __ 1993 : 
Source: Data provided by Eu rastat. 
Fig. 2.1.1. Population age structure in EC, 
1970 and 1993, males and females 
Births per 
woman 
4.5-
3.5-
i i • i i . 
I WO 1992 1«4 1999 1999 1970 1972 1(74 197* 1979 1990 1992 1194 1999 1999 1990 
—-• EC Greece ••••••• Portugal 
-_- Belgium ' Ireland A Spain 
o Denmark -4— Italy -•>- U.Kingdom 
• France — Luxembourg 
o Germany -';- Netherlands 
Source: OECD. Health Data Base. 1993. 
Fig. 2.1.2. Trends in total fertility rates, 
1960-1990 
44 
Thousands 
160CT 
1200-
800-
400* 
0 TTT 
400--Ö-Immigraton 
**•• • 
800 -
1200-Emigration 
1600-
Bel Den Ger Ire Ita Lux Net Por Uk 
_5| 1980 gH 1992 
Source: Data provided by EUROSTAT 
Note: France. Greece and Soain not included, because 
of lack of data. Data not available for Ireland and 
Portugalin 1980 
Fig. 2.1.3. Annual immigration to and 
emigration from EC countries, 1980 and 1992 Life expectancy 
at birth, in years 
78-
xl/ii-. m 
68- ' I ! i 
1970 1972 1974 1976 1978 1960 1962 1964 1986 1966 1990 1992 
—~• EC Greece •- Portugal 
-*- Belgium -- Ireland A- Spain 
o Denmark -f- Italy -•>- U.Kingdom 
• France — Luxembourg 
Germany -O- Netherlands 
Source: WHO/EURO. HFA Data Base 
Luxembourg: 3 year moving average 
Note: There was an artificial decline in Portugal in 1990. due 
to post-census change in population 
Fig. 2.2.1. Life expectancy at birth, 
total population, 1970-1992 
Fig. 2.2.2. Life expectancy at birth and real GDP around 1991, 
in selected countries 
oeu *USA 
23000 TV» 
B«9l OOP pt cacma (PPP$) 
Source: WHO/EURO Health for all database and UNDP. Human development report 1994. New York. 1994. 
Note: Includes average oi EC, OECD and Nordic countnes. 
45 
C Ountiys cosnon m 1970-107 J 
—} Country's oosition m 1991/1992 
Noie: Trio ta»* nciuOes tne EC memoer countries ana 11 maustnaizea 
countries mar rank in me too ot tne wona The ronicng s seromve 
to rjtterences n penoooafion 
rtotv. Soon Sweoen ana USA 1990 
1970 estimate for Germany wo» coieuoteo as o weigntea averooe tor me 
Feaera Reouotc ot Germany Derore reunmconon ana me German Democratic 
BeouOiic wim weionrj 0 8 ana 0.2 resoecrtvetv 
mere was an artificial oecnne n Portugal in 1990 aue to Dost-census cnonge m ooouiahon 
Sourea- WHO/EURO-HPA D»t» Baaa and WHO World HaalBi 
Slatauc* Annual laavarai yaarn 
Fig. 2.2.3. Life expectancy in developed market-economy countries-
changes in rank between 1970/1971 and 1991 /1992 
46 
Mortality rate 
per 100 000 
4000 
3000 
2000-
1000-
0 2.5 7.5 12.5 17.5 22.5 27.5 32.5 37.5 42.5 47.5 52.5 57.5 62.5 67.5 72.5 
Age 
—— Best in Europe -*•- EC Average 
Source: WHO/EURO - HFA Data Base 
Fig. 2.2.4. Age-specific total mortality: 
Community average and best in Europe, 1990 
2.1 
3.0 
U 
)J 
0.5 
'0 ' 2Q 40 53 60 70 80 • rO ICO 
Source: Majnom d'intignano. Economic considerations at conference 
"Action on social inequalities and health*. London, 3-4 May 1994 
Fig. 2.3.1. Changes in male/female death ratios 
in France between 1920-1924 and 1985-1989 
Figures from Institut National de la Statifctjque et des Etudes Economiques 
(INSEE) 
47 
at death 
75-^ SMR 
180-
Blue collar White collar 
Source: Krichgässler K.U. Health and social inequities 
m FRG Social Science and Medicine 1990; 31: 252 
Fig. 2.3.2. Average age of insured population 
of males at death, Germany, 1975-1985 160-
140-
120-
100-
80-
60-tJ i --j • i 
i y ; J 
40-
1951 1961 1971 1981 
; | I.Professional 
i fc~;J II.Managerial and Technical 
; Hi Ilia.Non-manual skilled 
i H II Ib.Manual skilled 
I • IV.Partly skilled 
i • V.Unskilled 
Source: WHO/EURO - HFA Monitoring report, U.K. 
Note: A rate higher than 100 implies that the group has a 
mortality above the average 
Fig. 2.3.3. Standardized mortality ratios 
by social class, males of working age under-65, 
United Kingdom, 1951-1981 
NUMBER 
OF AREAS 
12| 
231 
1861 
21 I 
0 
Source: Commission ot tne European Communities 
European Community Atlas ot avoidable death. 
Fig. 2.3.4. All-causes mortality, all ages, standardized mortality ratios, 
by administrative areas, EC, 1980/1984 
48 
Fig. 3.0.1. Main causes of death; 
profile by age, EC, 1991 
MM Ill defined causes 
f~~] Other 
SS External causes 
\é& Cancer 
H Diseases of the circulatory system 
H Congenital anomalies 
Source: WHO/EURO Health tor all database. 
Note: This figure shows only the relative proportions at given 
ages 
49 
Fig. 3.0.2. Distribution of total deaths by cause, age and sex. EC. 1991 
1-14 years, males 
Total deaths: 8 700 1-14 years, females 
Total deaths: 6 200 
15-34 years, males 
Total deaths: 65 500 15-34 years, females 
Total deaths: 22 800 
35-64 years, males 
Total deaths: 422 000 35-64 years, females 
Total deaths: 210 000 
65+ years, males 
Total deains: 1 227 000 65+ vears. females 
Total deaths: 1 497 000 
. ' Accidents C3 Other cancer • Breast cancer • Heart EPI Other CVD 
' Respiratory HI Lung cancer LZJ Stroke Hi Suicide ZZ\ Other causes , 
Source: WHO/EURO Health for all database. 
50 
Deaths per 
1000 live births 
50- • 
40-
30-
20-
10- o e 
1970 1972 1974 1976 1978 1960 1962 1964 1986 1988 1990 1992 
—^- Highest in EC o Lowest in EC 
— EC Average 
Source: WHO/EURO, HFA Data Base 
Fig. 3.1.1. Infant mortality rates in EC, 1970-1992 
Fig. 3.1.2. Prevalence per million population of haemoglobin disorders, EC countnes, 1992 
Source: Modell, B. EC concerted action on developing patient registers as a tool for improving service delivery for haemoglobin 
disorders. 
51 
Spain j 
U.Kingdom 
2 4 6 8 
DMF index 
DMF=Decayed, Missing or Filled teeth 
1980 or r <irest 1990 
Source: WHO/EURO. HFA Data Base 
Fig. 3.1.3. DMFT index for 12 year-olds, 
1980 and 1990 400T._. 
A 
i/ V A à—A ^ * 1 
»•«CI»'*'*!*'»'*1*1* 0 . • I • ' • 
1980 1982 1984 1986 1988 1990 1992 
Spain Italy • Netherlands 
Source. WHO/EURO-HFA Data Bas* 
Fig. 3.1.4. Measles incidence 
in selected countnes. 1980-1993 
Benaviour 
SmoKes every oay 
Dnnn aiconoi weekly or more often 
Exercises out ot scnool naif hour or less 
Eats whole wneat/rye oread daily or more often 
Eats sweets or chocolate more tnan once daily 
Brush teeth more man once a day 
Often tert low (depressed) in last cix months Belgium 
% Males 
11 
37 
12 
57 
27 
30 
10 % Females 
13 
24 
37 
SB 
31 
56 
21 UK (Scotland) 
% Males 
12 
32 
15 
51 
28 
49 
11 % Females 
13 
26 
28 
55 
17 
78 
24 Spam 
% Males 
12 
42 
22 
20 
16 
24 "/• Females 
19 
29 
56 
21 
21 
48 
14 
Source. * King AJ. Coles B. The health ot Canada's youtn: views and oehaviours ot 11-. 13- ana 15-years 
olds trom 11 countries. Canada. Minister ot Supply and Services. 1992. various tables 
Fig. 3.2.1. Adolescents, 15 year-olds' behaviour in selected countries, 1990 
' Original data oemg requested trom tne HBSC protect group (a WHO collaboration study) 
secretariat in Norway 
Finland 
Spam p: 
UK (Wales) ~ 
Norway ~ 
Sweden ~ 
UK(Scotiand) ~ 
Belgium ~ 
Austna ZZ J 15 years 
13 years 
| 11 years 
5 10 15 20 
Per cent daily smokers 25 
Source:* King AJ. Coles B. The health of Canada's youth: 
views and behaviours of 11-, 13- and 15-years 
olds from 11 countries. Canada. Minister of Supply 
and Services, 1992, various tables. 
Fig. 3.2.2. Daily smokers in selected countries 
females at ages 11, 13 and 15 years, 1990 
'Original data being requested from the HBSC project group 
(a WHO collaborating study) secretariat in Norway. Belgium 
Denmark 
France 
Germany 
Greece 
Ireland 
Italy 
Luxembourg 
(Motherland 
Portugal* " 
Spain K' -"; • ;'""'•'•"•{ 13 
United Kingdom 
52 0 10 20 30 40 50 60 
Births per 1000 women aged 15-19 
HI Around 1980 £3 Around 1990 I 
Source: WHO/EURO, HFA Data Base 
'Note: Portugal, 1985 data 
Fig. 3.2.3. Live births per 1000 women 
aged 15-19,1980 and 1990 < 
1000-* 
800-
600 -
400-
200-
Peoestnans cyclists UM, 
Motor Car Goods 
cyclists Occupant vehicle 
occupant 
Victim of accident 
Agent of accident 
• ..: Alone 
•I Cyclist 
QB Motorcyclist Car 
Goods vehicle 
Source: Road accidents Great Britain 1992: the casualty report. 
London, Her Maiestys Stationery Office, 1993: table 23. 
Fig. 3.2.4. Road deaths In the United Kingdom 
by means of transportation, 1992 
% change 
100-
75-
50-
25~ ~~ n ipi 
W-® ill 
-25-
-50-
-75-EE 
_J-2 Î 
-100-
Bel Den Fra Ger Gre ire Ita Lux N9t Por Spa Uk 
Killed Injured 
Source: Economic Commission for Europe. 
Statistics of road traffic accidents in Europe, 
vol. 39. Geneva. United Nations. 1994: table 2. 
Note: Greece. Italy and Portugal. 1985-92 
Luxembourg, 1985-90 
Fig. 3.2.6. Change in road traffic deaths and 
injuries, 1985-1992 53 SDR per 
100 000 
40-r 
1970 1972 1974 1976 1978 1980 1982 1984 1986 1988 1990 1992 
—~ EC Greece • Portugal 
-A- Belgium - Ireland ù. Spain 
-o- Denmark -+- Italy •- U.Kingdom 
••• France — Luxembourg 
• Germany • Netherlands 
Source: WHO/EURO. HFA Data Base 
Luxembourg: 3 years moving average 
Note: trends in Portugal affected by post-census change 
in population in 1990. 
Fig. 3.2.5. Trends in road traffic deaths, 
age-standardized death rates, 
all ages, 1970-1992 
Deaths per 
100 000 
8-
4-
1970 1972 1974 1976 1978 1980 1982 1984 1986 1988 1990 1992 
—» EC (excl. Italy and Potugal) ! 
^*V- Italy 
-•>- Portugal i 
Source: WHO/EURO- HFA Data Base 
Note: Crude death rates 
Fig. 3.2.7. Trends in homicide rates 
in males aaed 20-34 years 
^iç,. »i.o.t. ûistnDution of main cancers 
in men and women by site, 
Italy and the United Kingdom, 1983-1987 
Cancer site 
Oesophagus 
Stomach 
Pancreas 
Colon 
Rectum 
Luna 
Bladder 
Skin melanoma 
Lymphoma 
Breast 
Cervix 
Body ol uterus 
Ovary 
Prostate Male 
UK (England I Italy 
& Wales) % | (Varese) % 
i 
2.7 | 2.2 
7.4 j 9.6 
3.1 j 2.5 
7.2 j 7.1 
5.8 I 4.4 
28.1 
7.6 
1 23.9 
9.2 
I 1 
3.4 | •: 
| 
I 
I 
I 
I 
. | 
-.0.9 i 7.0 
Other ! 22.7 27.0 Female 
UK (England 
& Wales) % Italy 
(Varese) % 
I 
2.1 I 0.5 
4.8 I 8.8 
3.2 j 2.6 
9.2 i 9.4 
4.7 I 4.2 
I 
11.1 ! 4.2 
3 j 2.7 
1.9 ! 1.8 
2.9 ! 4.2 
r 
24.8 | 28.2 
4.4 
3.8 
5.1 2.8 
6.1 
4.5 
19 ! 19.8 
Source IARC. Cancer incidence in five continents. Lyon. 1992 
Note The figure shows the distnbution of cancers by site based on aver-
aae annual incidence 1983-1987 
SDR per 
100 000 
20^ 
15 + FEMALES 
o o 
o 
O-, 
-1 V ••••f 
(•.i i i i i i i I ! I I i i i 
1970 1972 1974 1976 1976 1980 1962 1964 1966 1968 1990 1992 
—• EC •> Greece m Portugal 
-*- Belgium ' - tiwana £- Spam 
O Denmark H- Raiy -•- U.Kingdom 
, • France — Luxembourg 
• Germany <- Netherlands 
Source: WHO/EURO. HFA Data Base. 1993 
Note: trends in Portugal affected by post-census change 
in population in 1990. 
Fig. 3.3.3. Trends in female lung 
cancer deaths, age-standardized death rates. 
age 0-64 years, 1970-1992 SDR per 
100 000 
60^ MALES 
50 J-* **w ,' *s 
0-f— 
1970 1972 1974 1976 1978 1980 1982 1984 1986 1988 1990 1992 
^~ EC Greece 
-à- Belgium - Ireland 
o Denmark -+- Italy 
• France — Luxembourg 
• Germany -O- Netherlands Portugal 
Spain 
U.Kingdom 
Source: WHO/EURO, HFA Data Base, 1993 
Note: trends in Portugal affected by post-census change 
in population in 1990. 
Fig. 3.3.2. Trends in male lung cancer deaths, 
age-standardized death rates. 
age 0-64 years, 1970-1992 
112.6 
0 40 80 120 160 
standardized rates per 100 000 
1970 Eg} 1985 
54 Source: lARC-Trends in cancer incidence and 
mortality. Lyon, 1993 
Fig. 3.3.4. Breast cancer annual incidence 
in registries of selected EC countnes, 
1970 and 1985 
SDR per 
100 000 
Fig. 3.3.5. Male mortality from stomach cancer. 
age-siandardized aeath rates, all ages. 
m selected EC countnes. 
1970-1974 and 1985-1989 
20 40 
SDR per 100000 
Source: WHO/Geneva. Wo* Health Statistics Annual 1993. Ge­
neva. 1994. e ~->r"\ 
~->-
-. n o o o c , 
A-A. 
*M!.THO 
20+ ; 
14 '•• 
1970 1972 1974 1976 1«7« I960 1962 1964 1«es 19M 1990 1992 
L EC 
Belgium 
Denmark. 
Prance 
Germany <"- Greece -e>~ Portugal 
• Ireland û Spam 
-+- Italy -«- U.Kingdom 
— Luxembourg 
~- Netherlands 
Source WHO/EURO. HFA Data Base 
Luxembourg: 3 year moving average 
Note: trends ot Portugal affected by post-census change 
m population in 1990. 
Fig. 3.3.6. Trends in mortality from coronary heart 
disease, age-standardized death rates, 
age 0-64 years, 1970-1992 
i COUNTRY % Current I Median 
smokers body mass 
inoex 
I Ka/sa.m % high 
blood 
pressure 
'• Belgium (Ghent) j 52 j 26 1 i 13 
| Denmark (Glostrupl | 61 I 25.4 j 14.9 
j France (Haute- j 43 I 25.5 
| Garonne) I 
i Germany (Augsburg i | 39 j 26.8 25.7 
27 
j italv(Fnuli) j 37 j 26.3 i 33.9 
i Soam (Catalonia) ' 57 , 26 5 | 8 4 
i UKingdom (Glasgow) | 62 | 25 4 32 Median 
Cholesterol 
mmoWl % with 2* 
nsk 
(actors 
6.1 i 23 
6.2 33 
5.9 1 26 
6.1 j 29 
n.a. n.a. 
n.a n.a. 
6.2 | 43 
Source: WHO-MONICA proiect. World Health Quarterty, vol. 41. no.3/4. 1988 
ig. 3.3.7. Risk factors in men in 7 EC regions 
55 Belgium (Ghent) 
Denmark(Glostrup) L^^'^^^i529 
^^^^ 141 
France (Toulouse) 
Germany (Augsburg) 
Italy (Fnuli) 
Spain (Catalonia) L 
11 Kingdom < JIISOOVK) •'///S/.-s, ,, ,-//,/. 
256 WA*& 
0 100 200 300 400 500 600 700 800 900 
Rate per 100 000 
V/A Male Female I 
Source: Tunstall-Pedoe H.et al.. 
Myocardial infarction and coronary 
deaths in the WHO MONICA proiect. 
Circulation 1994:90:583-612 
Fig. 3.3.8. Heart attack rates by sex, 
age 35 to 64, 7 EC regions 
50-35-
30-
30-
20-
10-
1970 1972 1974 1976 1978 1980 1982 1984 1986 1988 1990 1992 
EC 
aV Belgium 
~ Denmark 
• France 
- Germany Greece 
Ireland 
Italy 
Luxembourg 
Netherlands Portugal 
Spain 
U. Kingdom 
Source: WHO/EURO. HFA Data Base 
Luxembourg: 3 year moving average 
Note: trends m Portugal affected by post-census change 
in population in 1990. 
Fig. 3.3.9. Trends in mortality trom 
cerebrovascular diseases, age-standardized 
aeath rates, age 0-64 years, 1970-1992 
Fig. 3.3.11. Estimated prevalence 
of some chronic diseases 
(from a variety of localized studies) 
Chronic disease Men Women 
Rheumatoid arthritis 
Osteoarthritis of any joint 
Rena! failure 
Diabetes 
Asthma 
Epilepsy 2% 3% 
50% of adults 
P0 per 100 000 
2% at age 40+, rising to 6% in elderly 
3-5% 
one in 200 
Source: Vanous sources, see note. 
Note. Community-wide inlormation is not available, and these estimates have 
been quoted to give some information on the extent of the problem. The esti­
mates are derived tram a wide vanety of sources and in general are based on 
very localized studies. They should not theretore be taken as representative of 
prevalence in the Community. 
56 25 
• • 
•-• 
0-*-
1970 1972 1974 1976 1978 1980 1982 1984 1986 1988 1990 1992 
— EC 
-*V- Belgium 
o Denmark 
•• France 
° Germany Greece ••- Portugal 
- Ireland à Spain 
-+- Italy •- U.Kingdom 
— Luxembourg 
-> Netherlands 
Source: WHO/EURO, HFA Data Base 
Luxembourg: 3 year moving average 
Note: trends in Portugal affected by post-census change 
in population in 1990 
Fig. 3.3.10. Trends in mortality by liver diseases 
and cirrhosis, age-standardized death rates, 
age 0-64 years, 1970-1992 
Belgium 
Denmark 
France 
Germany 
Greece (104) 
(64) (Total number of fatal accidents) 
(1096) 
(1704) 
(117) 
Ireland i (13) 
Italy 
Luxembourg 
Netherlands 
Portugal 
Spain 
U.Kingdom 
EC (1509) 
(13) 
(43) 
fc (414) 
(6511) 
5 10 15 «i0 25 
Death rates per million 30 35 
Source: Commission of the European Communities. 
Directorate-General of employment. 
Industrial Relations and Social Affairs. 
Occupational accident statistics in the Member States 
of the European Community. 
Luxembourg. DGV (unpublished) 1993. 
Note: Non-harmonized data 
Fig. 3.3.12. Occupational accident death rates 
per million population and 
totpi ntimher nf fatal accidents. 1992 
10 20 30 
Cases per 1000 employees 40 
Hi France (1986) ; Germany (1987) 
Source: EUROSTAT- Disabled persons: Statistical data. 
Luxembourg. 1991. Fig. 3.3.14. Trends in incidence of AIDS, 
1981-1993 
19B1 1982 1963 1994 1985 1906 1967 19SB 198S 1990 1991 1992 I99C 
Fig. 3.3.13. New cases of permanent disability 
recorded by social insurance in France and 
Germany, per year, per 1000 employees, 1986,1987 Source: WHO/EURO Health »or all database. 
Note: Data is by year of diagnosis and unadjusted lor reporting 
delays. Therefore the figures for latest years are actually higher. 
Fig.3.3.15. Cumulative AIDS cases 
(adults/adolescents) by country and 
transmission group (December 1994) 
•F VNi I» Ctit. VK U« W» C HE to» R* SP» 
rVofe: Totals at bottom ol columns give the cumulative cases up to 
31 December 1994. Incidence per 
100 000 
90-
iaW 
80- "-A. 
±-A 
70-
60 T, *-A 
* ',** 
0 — 
1974 1976 1978 1980 1982 1984 1986 1988 1990 1992 
— EC o Germany —— Spain 
-é- Portugal «* Italy Greece 
Source: WHO/EURO. HFA Data Base 
57 Fig. 3.3.16. Tuberculosis, 
rates of annual notification, EC average and 
selected countries, 1974-1993 
SDR per 
100 000 
35 T 
25 -r o o C 0 o o© 
•'u^i^i %. 
1870 1872 1974 1876 1878 I960 1982 19S4 I8AS 1966 1980 1892 
— EC --- Greece -•- Portugal ; 
-*- Belgium ~*~ Ireland ti- Spain i 
o Denmark H— Itary -•- U.Kingdom l 
• France — Luxembourg j 
• Germany ->- Neihertanos 
Source: WHO/EURO. H~A Da ia Oaso 
Luxembourg: 3 years rrv ving average 
Note: trenos tn Portugal attected by post-census change 
m population m 1990 
Fig. 3.3.17. Trencs in mortality by sudde and 
self-indicted injury, all ayes, 1970-1992 Denmark (Odense) 
France (Bordeaux) 
Italy (Emiiia-Romagria 
Netherlands (Leiden) 
Spain (Guipuzcoa) 
0 100 200 300 
Rale per 100 000 aged 15+ 
I I Male EB Female 
Source: WHO/EURO multicentre study on parasuiade 
Plaits et al. Ada Psychiat-scand. 1992.8537-104 
Fig. 3.3.18. Parasuicide rates 
in five EC towns and regions, 1989 12 I I I I I t >' I ! I M I I I I I I I I I M 
1970 1S72 1974 1976 197» 1980 »982 1984 1966 198» «990 1993 
•—EC -+- Italy 
-A- Belgium -*— Luxembourg 
o Denmark -o- Netherlands 
••- France -•- Portugal 
• Germany -û Spain 
-c- Greece -•- U.Kingdom 
-^ Ireland 
Source: WHCVEURO. HFA Dau base 
Luxembourg: 3 year moving average 
Note: trends in Portugal aflected by post-census change 
in population in 1990. 
Fig. 3.4.1. Trends in life expectancy at age 65, 
1970-1992 
Ftg. 4.1.1. Percentage of adult population (15+) 
wnoare regular smoKers, 1991-1992 
Bel Den Fra Gcr Gre Ire «a Lux Net Por Spa Uk EU 
Women 33 Mon 
Source. WHO/TOH database. 1994 (original source: 
EUROBAROMETER) 
Note: Estimate tor Germany is calculated as a weighted aver­
age wiin weiohts ol 0 8 and 0.2 lor tne Federal Republic of 
Germany Delore unification and the German Democratic Re­
public, respectively Fig. 4.1.2. Percentage of smokers 
wishing or trying to stop, 1993 
% 40 
BELDENFRAGEHGREIRE fTA LUXI^POBSPÂW 
Source: WHO/EURO TOH database. 1994 
58 
Fig. 4.1.3. Relative price index of 20 cigarettes 
(popular brand) in EC countnes, 1992 
153.2 
0 20 40 60 80 100 120 140 160 
Relative pnce (EC average = 100) 
Source. Joossens. L et al.. Taxes on tobacco products. Euro­
pean Bureau tor Action on Smoking Prevention. Brussels, 1992. 
Note: The relative pnce shows the consumer pnce relative to 
general pnce levels. Fig. 4.1.4. Annual alcohol consumption in litres 
per person, 1970 and 1990 
United Kingdom! 
EC* 
12 
Litres per person 
Source: WHO/EURO Health for all database. 
Note: Estimate for Germany ts calculated as a weighted aver­
age with weights of 0.8 and 0.2 for the Federal Republic ol 
Germanv before unification and the German Democratic Re­
public, respectively. 
incidence per 
100 000 
5-r 
Fig. 4.1.5. Excise taxes on spirits (100% alcohol) 
in EC countries, 1992 
3316 
0 500 1000 1500 2000 2500 3000 3500 
Ecu per hectolitre 
Source: Lehto. J Approaches to alcohol control policy 
Copenhagen. WHO Regional Office for Europe. 1995 (WHO 
Regional Publications. European Senes. No 61). 4-r 
3 + 
W * 
. — * • A'..-
i960 1982 1984 1986 1988 1990 1992 
• Denmark 
A- France 
• Germany • Italy 
Netheflands 
Portugal Spam 
U.Kingdom 
Source: WHO/EURO. HFA Data Base 
Note: includes only EC countnes tor which information 
is available. 
Fig. 4.1.6. Trends in deaths from overdose of illicit 
drugs, crude death rates, selected EC countnes, 
1980-1993 
Fig. 4.1.7. Percentage of adult population very 
overweight*, selected EC countnes, around 1990 
DEN FRA GER NET SPA UNK 
(Wesl) 
Mates £3 Females 
Source WHO/EURO Health lor all Monrtonna reports 
• Body mass moex 30* Kg/m* (31 + lor United Kingdom) 
59 
Fig. 4.1.8. Changing patterns of food consumption in the EC, 1970-1990 
Kg per 
capita 
20 -T 
18 u, 
16 T 
14 -
12--
10-
6 -
1o A-r ANIMAL FATS 
o a « o 
2 —*- 4 4 T • t 
SUGAR 1970 1972 1974 1976 1978 1980 1982 1984 1986 1988 1990 
Kg per 
capita 
45- A 
40-
35* 
c. ° o A 
30 
25 o o 
O « 0 © o Kg per 
capita 
160-r 
150 I 
i 
140 + 
i i 
130-1-
120 4 
1104 CEREALS & PRODUCTS 
o o • • 
100 + 
1970 1972 1974 1976 1978 1980 1982 1984 1986 1988 1990 
Kg per 
capita 
11 r 
10 4 OILS CONTAINING MAINLY 
POLYUNSATURATED FATTY ACIDS 
o e 
20 
1970 1972 1974 1976 1978 1980 19B2 1984 1986 1988 1990 
Kg per 
capita 
350 
VEGETABLES & FRUITS 
300 
250 
200 
150 ooo ft o 
o o 
A-r* 
100 
1970 1972 1974 1976 1978 1980 1982 1984 1986 1988 1990 5 I H 
1970 197? 1974 1976 1978 1980 1982 1984 1986 1988 1990 
Kg per 
capita OLIVE OIL 
12 ; o 
o „ o O o o n o 
10 4 
8 ; 0 „°o °°o 
0 )A-iA-|ArAiAiAiA4AiAiAiAiA|AiAiArATATATArnàTéi 
1970 197? 1974 1976 1978 i960 1982 1984 1986 1988 1990 
Noie The group ot southern countnes are Greece Italy Portugal I __ ,-,«•« .„,,_ . . 
ana Soain The remaining eight EC counlnes constitute the ! """" EC A NORTH o SOUTH Source WHO/EURO, Nutritton/PC 
nonnem aroup • • ' (based on FAO tood balance sheet data) 
60 
Fig. 4P? Households lacking sanitary taaMies «1 the EC. 1985 
ENVIRONMENT RELATED DISEASES 
Cancer: especially lung and skin 
Respiratory diseases: bronchitis, emphysema 
Allergic diseases: eczema, astnma 
Nervous system diseases: drain ana penpnerai nerve 
disorders 
Reproduction: miscarnage, congenital anomalies, 
infertility 
Source: Environment and public health: an 
epidemiological research programme. 
Solna, Swedish Environmental Protection 
Agency, 1993 
Fig. 4.2.1. - Environment related diseases Country No inside lavatory No nside bain or chower 
Households Households 
i%) (ihousands) 
Belgium 
Denmark 
France 
Germany 
Greece 
Ireland 
Italy 
Luxembourg 
Netherlands 
Portugal 
Spam 
United KinoOom People 
(thousands) Households 
(*) 
516 
68 
2 046 
557 
515 
63 
392 
1 
0 
\ 397 
963 
205 1 398 
149 
5 524 
1 337 
1 596 
220 
1 177 
2 
0 
4 612 
3 468 
534 Households 
(thousands) 
795 
135 
1 723 
1 672 
522 
84 
1 425 
4 
129 
t 397 
2 047 
228 People | 
(thousands) j 
2 145 
297 
4 652 
4 012 
1 617 
295 
4 274 
11 
348 
4 612 
7368 
593 
Source: FEANTSA. Homelessness: a condition or a soaal process? An overview lor the 12 Momocr Stales ol the 
EU. Brussels. 1994. 
Fig. 4.2.3. Housing in Germany, 
western and eastern Lander, 1987-1991 Fig. 4.2.4. Estimated homelessness 
per 1000 inhabitants in the EC, 1991-1992 
„ . Western Eastern 
Category Lânder Lander 
Private households (1990) 27.6 million 6.6 million 
Flats (1990) 26.8 million 7.0 million 
Built before 1919 18% 37% 
Owners ot flats (1990): 
• State/Local Authority 3% 41% 
- Association 13% 17% 
• Private 84% 42% 
Living space/flat (1987/89) 85 m3 65 m2 
Average monthly rent per flat: 
-1987/89 486 DM , 62 DM 
- 1991/92 589 DM 298 DM 
Housing shortage 1.5 million 1 million 
(estimated number of flats) 
Source: EC Observatory on policies to combat soaal 
exclusion. Social exclusion in the Federal Republic of 
Germany. Belgium jHHalH 2.6 
Denmark |o.6 
France tÊÊÊMWÊÊMM 
(W) Germany tÊÊÊÊÊÊÊÊÊÊ 
Greece JEM 1 
Ireland H|l.4 
Italy _•••• 2.7 
Luxembourg _JHH 1.5 
Netherlands WÊÊÊÊÊ2 
Portugal 10.3 
Spain H 0.8 
United Kingdom ••••• 
ECU [7.5 
0 3 6 9 12 
Rate per 1000 population 
Source: FEANTSA. Abandoned: Profile of Europe's home­
less people, Brussels, 1994. Table 1. 
Fig. 4.2.5. Percentage of population 
disturbed by noise, Germany, 1987 
80 T 
401 :m 
\*t£jù US 
l-su&H 
issa •' I Not oïstumed 
^'Disturbed ' -
,BB'Seriously disturbed 
ÏÏ&M _ .HEEL 
AJ reran 
Source. The State of the Environment in the European 
Community. European Commission. Figure 5.4. 
• 1986. Fig. 4.2.6. Effects of urban car traffic, 1991 
BB 
BEL DEN FRA OEU GRE IRE hA UUX NET POR SPA UNK EC 
I I Bearable P3 Hardly bearable • Unbearable 
Source: EUROBAROMETER. Urban congestion and public 
transport. Basic tables: 19 September 1991. 
Fig. 4.2.7. Heart attack rates in cyclists and 
non-cyclists, males, United Kingdom, 1976-1986 
Vigorous cyang 
htocyowo.. 
nowgorous 
«nose 
Source: Morns, J.N. et al., British health journal. 63.325-
(1990). 61 
: j. --.2. W4... r»'.fi! sjsoenaed black smo\e 
concentrations in selected EC cities, average 
over 1986-1991 
United Kingdom 
(Mancneaer) 
Source: WHO-ECEH. Urban BS. 
Fig. 4.2.8b. Total suspended particulates in 
selected EC cities, average over 1986-1991 
Spam 
(Barcelona) Fig. 4.3.1. Unemployment levels in the EC. 
Japan and USA 
60 «2 64 66 61 70 73 74 76 71 10 62 14 16 «1 »O 62 94 
Source: European Commission, Growth, competitiveness, 
employment: The challenges and ways torward into the 21 st 
century (white paper). Luxembourg, 1993. 
Source- WHO-ECEH, Urban TSP 
Fig. 4.3.2. Percentage of unemployed under 25 years of age. EC. 1992 
% of unemployed 
< 25 years 
<10 
10-20 
20-40 
>40 
No data 
ttZ23 
Source. Commission of the European Communities. European soaal policy, opttons for the future. Green Paper, 
Luxembourg. 1993. 
62 
Per cent 
ot population 
80-
Bel Den Fra Ger Gre Ire lu Nel Por Spi Uk EC 
[23 National Average ME EC Average 
Source: EUROSTAT. Povenvin figures: Europe 
m ne early 1980s. Luxembourg 1990 
Fig. 4.3.3. Per cent of the population with 
household expenditure less than half of the 
national average and EC average household 
expenditure, 1985 40 60 80 100 120 140 160 
Relative pooe (EC average « 100) 
Source: European Commission 
On tne ocrâmes ot an industrial policy tor the 
pharmaceutical sector in the European 
Community. Com (93) 718. Brussels. 1994 
Note: The relative pnce show* the consumer pnce 
relative to general pnce levels 
Fig. 4.4.1. Relative price index ol 
pharmaceuticals, 1993 
SMRS 
Source: Commission of the European Communtities 
European Community Atlas of avoidable death. 
Fig. 4.4.2. Standardized mortality ratios for appendicitis, ages 5-64 years, EC, 1980/1984 
63 
2 3 
Years 
DenmarK -•- Italy 
France —- Netherlands 
Germany — Spain 
Soot» loco '<9«m U.Kingdom Bel Den Fra Ger Gre Ire tta Net Por Spa Uk 
I CZ3 198n • 1989 • 
Source: OECD. Health database. 1993 
* i9B3oata 
Fig. 4.4.3. Variation in survival (%) 
for colon cancer, from cancer registries 
m 7 EC countries. 1978-1985 Fig. 4.4.4. Psychiatric hospitals -
beds per 1 UUO population, 1980 and 1989 
Fig. 4.4.5. Biomedical and health research 
programmes, EC, 1978-1994 
N«of National ECU 
Programme Duration projects teams (million) 
FIRST 1978-81 3 100 1.09 
SECOND 1980-63 7 230 2.32 
THIRD 1982-66 34 1200 13.30 
FOURTH 1987-91 135 4500 65.00 
BIOMED 1 1990-94 1,00 6650 150.00 
BIOMED 2 1994-1998 — ~ 336.00 
Source: Data provided by the Commission of the European 
Communities. DG Xll/E. 
64 
Annex 3 
Tables of causes of death, EC, 1991 
Table 1. Deaths according to cause. EC. around 1991 
Table 2. Life expectancy at birth, in years 
Table 3. Infant mortality rate, per 1000 live births 
Table 4. Standardized death rates, diseases of the circulatorv' system. 0-64 years, per 100 000 
Table 5. Standardized death rates, ischaemic heart diseases, 0-64 years, per 100 000 
Table 6. Standardized death rates, cerebrovascular diseases, 0-64 years, per 100 000 
Table 7. Standardized death rates, malignant neoplasms, 0-64 years, per 100 000 
Table 8. Standardized death rates, trachea/bronchus/lung cancer, 0-64 years, per 100 000 
Table 9. Standardized death rates, malignant neoplasm female breast. 0-64 years, per 100 000 
Table 10. Standardized death rates, external causes of injury and poisoning, all ages, per 100 000 
Table 11. Standardized death rates, motor vehicle traffic accidents, all ages, per 100 000 
Table 12. Standardized death rates, suicide and self-inflicted injury, all ages, per 100 000 
65 
Table 1. Deaths (in thousands) according to main groups of causes, EC, around 1991 
Cause of death 
-
Cardiovascular diseases 
Cancer 
External causes 
Infectious & parasitic 
diseases 
Respiratory diseases 
Mental and nervous 
system diseases 
III defined causes 
Digestive system diseases 
Endocrine, metabolic and 
immunity disorders 
Other diseases 
All causes Sex 
T 
F 
M 
T 
F 
M 
T 
F 
M 
T 
F 
M 
T 
F 
M 
T 
F 
M 
T 
F 
M 
T 
F 
M 
T 
F 
M 
T 
F 
M 
T 
F 
M ___________ 
All ages 
1525 
833 
692 
862 
382 
480 
189 
70 
119 
25 
12 
13 
268 
120 
148 
114 
62 
52 
76 
35 
41 
158 
75 
83 
101 
58 
43 
166 
98 
68 
3486 
1747 
1739 YEARS 
0 
0.4 
0.2 
0.2 
0.1 
0.05 
0.05 
1.0 
0.4 
0.6 
0.5 
0.2 
0.3 
0.7 
0.3 
04 
0.7 
0.3 
0.4 
5.1 
2.0 
3.1 
0.2 
0.1 
0.1 
0.4 
0.2 
0.2 
19.9 
8.6 
11.3 
28.9 
12.3 
16.6 1-14 
0.7 
0.3 
0.4 
2.2 
1.0 
1.3 
5.1 
1.8 
3.3 
0.5 
0.2 
0.3 
0.6 
0.3 
0.3 
1.3 
0.6 
0.7 
07 
0.3 
0.4 
0.2 
0.1 
0.1 
0.5 
0.2 
0.3 
2.3 
1.0 
1.2 
14.1 
5.8 
8.2 15-24 
1.7 
0.6 
1.1 
2.9 
1.1 
1.7 
22.9 
4.4 
18.5 
0.4 
0.1 
0.2 
0.8 
0.3 
0.5 
2.3 
0.6 
1.7 
1.5 
0.4 
1.2 
0.3 
0.1 
0.2 
0.9 
0.3 
0.6 
1.3 
0.6 
0.7 
34.9 
8.6 
26.4 25-34 
4.7 
1.5 
3.2 
6.7 
3.4 
3.3 
23.7 
4.5 
19.2 
0.8 
0.2 
0.5 
1.4 
0.4 
0.9 
4.0 
3.0 
2.8 
0.7 
2.1 
2.1 
0.6 
1.4 
5.7 
1.1 
4.6 
1.5 
0.8 
0.7 
53.4 
14.2 
39.2 35-64 
179.8 
47.5 
129.3 
250.3 
100.1 
150.2 
5£.~ 
14.9 
43.8 
5.2 
1.6 
3.6 
25.2 
7.7 
17.5 
19.8 
6.5 
13.2 
16.6 
4.5 
12.1 
46.1 
14.0 
32.1 
17.3 
5.7 
11.6 
14.2 
6.5 
7.8 
630.1 
209.0 
421.1 65+ 
1340 
783 
557 
600 
276 
324 
77.Û 
43.7 
33.9 
18.4 
9.9 
8.5 
239 
111 
128 
86.0 
52.7 
33.3 
49.2 
27.4 
21.8 
109.6 
60.4 
49.2 
76.9 
51.4 
25.5 
127.6 
80.6 
47.0 
2725 
1497 
1228 
66 
Table 2. Life expectancy at birth, in years 
Historical year 
Year Value Latest 
available year 
Year Value 
EC 
Belgium 
Denmark 
France 
Germany 
Greece 
Ireland 
Italy 
Luxembourg 
Netherlands 
Portugal 
Spain 
United Kingdom 1970 
1970 
1970 
1970 
1970 
1970 
1970 
1970 
1971 
1970 
1971 
197() 
1970 71.8 
71.(1 
73.5 
72 9 
70.5 
73.8 
70.7 
71.6 
69.7 
67.0 
72.8 
71.8 1991 
1989 
1992 
1991 
1991 
1991 
1991 
1990 
1992 
1991 
1992 
1990 
1992 76.5 
75.7 
75.4 
77 7 
75.7 
77.4 
75.0 
77.2 
76.1 
77.3 
74.4 
77.0 
76.4 
Table 3. Infant mortality rate, per 1000 live births 
Historical year 
Year Value Latest 
available year 
Year Value 
EC 
Belgium 
Denmark 
France 
German) 
Greece 
Ireland 
Italy 
Luxembourg 
Netherlands 
Portugal 
Spain 
United Kingdom 1970 
1970 
1970 
1970 
1970 
1970 
1970 
1970 
1971 
1970 
1971 
1970 
1970 __.j 
21.1 
14.2 
15.1 
23.6 
29.6 
19.5 
29.6 
20.5 
12.7 
49.8 
20.8 
18.5 1991 
1989 
1992 
1991 
1991 
1991 
1991 
1990 
1992 
1991 
1992 
1990 
1992 7.5 
8.5 
6.5 
7.3 
6.9 
9.0 
7.6 
8.0 
7.2 
6.5 
9.3 
7.6 
6.6 
67 
Table 4. Standardized death rates, diseases of circulatory system, 
0-64 years, per 100 000 
Historical year 
Year Value Latest 
available year 
Year Value % 
Change 
EC-
Belgium 
Denmark 
France 
German) 
Greece 
Ireland 
hah 
Luxembourg 
Netherlands 
Portugal 
Spain 
United Kingdom 1970 
1970 
1970 
1970 
1970 
1970 
1970 
1970 
1971 
1970 
1971 
1970 
1970 102.5 
ll 6.4 
96.5 
74.8 
I01.7 
68.3 
149.3 
96.7 
149.5 
99.3 
109.0 
93.3 
140.5 1991 
1989 
1992 
1991 
1991 
1991 
1991 
1990 
1992 
1991 
1992 
1990 
1992 62.4 
58.6 
66.3 
40.6 
74.1 
65.6 
87.3 
51.5 
63.6 
60.4 
64.9 
51.3 
79.3 -39.1 
-49.7 
-3 1.3 
-45.8 
-27.2 
- 3.9 
-41.6 
-46.7 
-57.4 
-39.1 
-40.4 
-45.1 
-43.5 
Table 5. Standardized death rates, ischaemic heart diseases, 
0-64 years, per 100 000 
Historical year 
Year Value Latest 
available year 
Year Value % 
Change 
EC 
Belgium 
Denmark 
France 
Germany 
Greece 
Ireland 
Italy 
Luxembourg 
Netherlands 
Portugal 
Spain 
United Kingdom 1970 
1970 
1970 
1970 
1970 
1970 
1970 
1970 
1971 
1970 
I97l 
1970 
1970 46.0 
60.6 
63.1 
23.7 
47.8 
23.3 
88.1 
36.9 
69.3 
64.1 
30.0 
17.5 
86.6 I99l 
1989 
1992 
1991 
1991 
I99I 
I99l 
1990 
1992 
1991 
1992 
1990 
1992 32.6 
26.6 
40.2 
15.6 
37.7 
30.6 
60.7 
24.2 
30.6 
34.6 
23.4 
20.4 
55.9 -29.2 
-56.1 
-36.3 
-34.3 
-21.2 
31.5 
-3).I 
-34.5 
-55.8 
-46". 0 
-21.9 
16.4 
- 5.4 
68 
Table 6. Standardized death rates, cerebrovascular diseases, 
0-64 years, per 100 000 
Historical year 
Year Value Latest 
available year 
Year Value /o 
Change 
EC 
Belgium 
Denmark 
France 
German) 
Greece 
Ireland 
Itai) 
Luxembourg 
Netherlands 
Portugal 
Spain 
United Kingdom 1970 
1970 
1970 
1970 
1970 
1970 
1970 
1970 
I97l 
1970 
197I 
1970 
1970 23.0 
22.6 
15.4 
22.5 
20.8 
20.4 
32.5 
25.2 
18.9 
16.8 
33.6 
23.8 
26.8 1991 
1989 
1992 
I99l 
I99l 
1991 
1991 
1990 
1992 
1991 
1992 
1990 
1992 12.0 
10.6 
12." 
9.0 
12.0 
15.4 
11.5 
11.8 
14.2 
8.8 
26.5 
11.6 
12.5 -49.0 
-52.9 
-17.3 
-59.8 
-42.5 
-24.4 
-64.5 
-53.3 
-25.1 
-47.6 
-21.2 
-51.4 
-53.3 
Table 7. Standardized death rates malignant neoplasms, 
0-64 years, per 100 000 
Historical year 
Year Value Latest 
available year 
Year Value % 
Change 
EC-
Belgium 
Denmark 
France 
German) 
Greece 
Ireland 
ltal) 
Luxembourg 
Netherlands 
Portugal 
Spain 
United Kingdom 1970 
1970 
1970 
1970 
1970 
1970 
1970 
1970 
1971 
1970 
1971 
1970 
1970 ep -
100.0 
100 I 
91.7 
93.5 
69.4 
99.5 
93.5 
llO.l 
98.6 
78.6 
74.3 
105.9 199I 
1989 
1992 
1991 
I99I 
I99l 
1991 
1990 
1992 
1991 
1992 
1990 
1992 88.7 
93.5 
99.3 
94.8 
88.5 
70.3 
92.0 
90.0 
92.5 
86.1 
76.8 
80.0 
89.7 -4.5 
-6.5 
-0.8 
3.3 
-5.4 
1.2 
-7.5 
-3.8 
15.9 
I ° 7 
•2.3 
7.7 
15.3 
69 
Table 8. Standardized death rates, trachea/bronchus/lung cancer, 0-64 years, per 100.000 
Historical year 
Year Value Latest 
available year 
Year Value % 
Change 
EC 
Belgium 
Denmark 
France 
German) 
Greece 
Ireland 
hah 
Luxembourg 
Netherlands 
Portugal 
Spain 
United Kingdom 1970 
1970 
1970 
1970 
1970 
1970 
1970 
1970 
1971 
1970 
1971 
1970 
1970 17.1 
22 9 
16.8 
12 ! 
14.1 
12.6 
21 7 
16.2 
26.9 
23.5 
6.6 
9.4 
29.9 1991 
1989 
1992 
1991 
1991 
1991 
1991 
1990 
1992 
1991 
1992 
1990 
1992 19.6 
24.8 
24.4 
19.7 
18.7 
18.4 
17.2 
21.0 
22.0 
21.8 
11.0 
16.6 
19.9 14.6 
8.4 
45.5 
62.6 
31.7 
46.4 
- 20.6 
29.4 
- 18.2 
- 7.1 
65.3 
76.2 
-33.6 
Table 9. Standardized death rates malignant neoplasm female breast, 0-64 years, per 100 000 
Historical year 
Year Value Latest 
available year 
Year Value % 
Change 
EC 
Belgium 
Denmark 
France 
German) 
Greece 
Ireland 
Italy 
Luxembourg 
Netherlands 
Portugal 
Spam 
United Kingdom 1970 
1970 
1970 
1970 
1970 
1970 
1970 
1970 
1971 
1970 
1971 
1970 
1970 18.3 
21.5 
25.0 
15.9 
18.0 
10.1 
22.0 
17.2 
22 2 
24.7 
15.0 
10.2 
25.7 1991 
1989 
1992 
1991 
1991 
1991 
1991 
1990 
1992 
1991 
1992 
1990 
1992 20.0 
24.6 
24.8 
17.7 
19.9 
13.8 
25.3 
19.0 
15.5 
23.6 
18.0 
16.5 
24.5 9.4 
14.8 
- 0.8 
11.4 
10.7 
37.5 
15.0 
10.6 
-30.3 
- 4.2 
20.1 
61.4 
- 4.5 
70 
Table 10. Standardized death rates, external causes of injury and poisoning, all ages, per 100 000 
Historical year 
Year Value Latest 
available year 
Year Value /o 
Change 
EC 
Belgium 
Denmark 
France 
German) 
Greece 
Ireland 
hah 
Luxembourg 
Netherlands 
Portugal 
Spain 
United Kingdom I 97() 
1970 
1970 
1970 
1970 
1970 
1970 
1970 
1971 
1970 
1971 
1970 
1970 67.2 
84." 
73.1 
91.0 
90.3 
45.5 
50.8 
56.1 
96.8 
63.3 
72.2 
43.0 
46.7 1991 
1989 
1992 
1991 
1991 
1991 
1991 
1990 
1992 
1991 
1992 
1990 
1992 48.3 
57." 
59." 
69.8 
49.6 
38.4 
42.0 
43.4 
60.2 
32.6 
63.4 
45.8 
30.7 -28.1 
-3 1.9 
-18.3 
.">! i 
-45.1 
-15.6 
-17.3 
-37.8 
-48.5 
6.5 
-34.2 
Table 11. Standardized death rates motor vehicle traffic accidents, all ages, per 100 000 
Historical year 
Year Value Latest 
available year 
Year Value % 
Change 
EC-
Belgium 
Denmark 
France 
Germany 
Greece 
Ireland 
hah 
Luxembourg 
Netherlands 
Portugal 
Spain 
United Kingdom 1970 
1970 
1970 
1970 
1970 
1970 
1970 
1970 
1971 
1970 
1971 
1970 
1970 22 5 
29.9 
24.0 
23.5 
31.4 
11.9 
17.1 
24.7 
27.3 
24.5 
29.0 
14.4 
13.8 1991 
1989 
1992 
1991 
1991 
1991 
1991 
1990 
1992 
1991 
1992 
1990 
1992 14.1 
17 4 
10.2 
15.7 
12.9 
20.7 
11.9 
14.4 
17.9 
7.8 
26.5 
19.3 
7.5 -37.5 
-41.8 
-57.5 
-33.4 
-59.1 
74.8 
-30.7 
-41.9 
-34.4 
-68.1 
- 8.4 
34.3 
-45.6 
71 
Table 12. Standardized death rates, suicide and self-inflicted injury, all ages, per 100 000 
Historical year 
Year Value Latest 
available year 
Year % 
Change 
Value 
EC 
Belgium 
Denmark 
France 
German) 
Greece 
Ireland 
hah 
Luxembourg 
Netherlands 
Portugal 
Spain 
United Kingdom 1970 
1970 
1970 
1970 
1970 
1970 
1970 
1970 
I97l 
1970 
1971 
1970 
1970 II.8 
16.4 
22 4 
15.9 
21.^ 
3.4 
2.1 
6.0 
13.4 
9.1 
9.6 
4.7 
7.9 1991 
1989 
1992 
1991 
1991 
1991 
1991 
1990 
1992 
1991 
1992 
1990 
1992 11.7 
17.8 
20.4 
18.9 
15.4 
3.4 
10.7 
6.8 
14.0 
10.2 
8.3 
7.1 
7.8 - 0.6 
8.8 
- 9.2 
19.0 
-28.8 
1.9 
41.9 
12.4 
4.5 
I 1.4 
-14.2 
50.1 
. "> *> 
72 
Annex 4 
Bibliography 
General references 
Commission of the European Communities. Directorate-general of Employment. Industrial Relations 
and Social Affairs. Commission communication on the framework for action in the field of public 
health. Luxembourg. Office for Official Publications of the European Communities. 
1993 (COM(93) 559Vmal). 
Commission of the European Communities. Directorate-general of Employment. Industrial Relations 
and Social Affairs. European social policy: options for the Union (Green paper). Luxembourg. Office 
for Official Publications of the European Communities, 1993. 
Commission of the European Communities. XXVllth general report on the activities of the European 
Communities. Luxembourg. Office for Official Publications of the European Communities. 1993. 
Commission of the European Communities. Directorate-general of Employment. Industrial Relations 
and Social Affairs. Growth, competitiveness and employment: the challenges and ways forward into 
the 21st century. Luxembourg. Office for Official Publications of the European Communities. 1993. 
Richards. T. Medicine in Europe. London. British Medical Journal Publications, 1992. 
World Development Report 1993: Investing in health. Washington, The World Bank, 1993. 
World Health Quarterly. 41(3/4), Table 2: 1988 Concern for Europe's tomorrow. Copenhagen, WHO 
Regional Office for Europe, 1994 (WHO Regional Publications, European Series, No. 53). 
Health in development: prospects for the 21st century. Geneva. World Health Organization, 1994 
(WHO/DGH/94.4. p. 36). 
The health of Europe. Summary of the second health for all evaluation. Copenhagen, WHO Regional 
Office for Europe. 1993 (WHO Regional Publications, European Series, No. 49.). 
73 
Chapter 1. Introduction 
1.1 Why a health report for the Community 
Secular trends in anthropometric data also in: Eveleth. P.B. & Tanner. J.M. Worldwide variation in 
human growth. Cambridge. Cambridge University Press. 1990 (Figs. 13 and 14). 
Fig. 1.1: Life expectancy in 1950 and 1960 has been calculated for all 12 EC countries as of 1^94. 
1.2 Describing health and its determinants 
Evaluation of the strategy for health for all by the year 2000. Seventh report on the world health 
situation, volume 5. Copenhagen, WHO Regional Office for Europe. 1986. And Health for all targets: 
the health policy for Europe. Copenhagen. WHO Regional Office for Europe. 1993 (European Health 
for All Series. No. 4). And Abelin. T. et al., ed. Measurement in health promotion and protection. 
Copenhagen. WHO Regional Office for Europe. 1987 (WHO Regional Publications. European Series. 
No. 22). And Ruwaard. D. et al., ed. Public health status and forecasts: the health status of the Dutch 
population over the period 1950-2010. The Hague. Rijksinstituut voor Voiksgezondheid en 
Miiieuhygiene, 1994. 
Chapter 2. The population s health 
2.1 Population 
Births: Eurostat. Demographic statistics 1994. Luxembourg. Office for Official Publications of the 
European Communities. 1992 (Series 3 A). And Demographic trends in the European Region. Copenha­
gen. WHO Regional Office for Europe, 1984 (WHO Regional Publications, European Series No. 17). 
Contraception rates: (personal communication), United Nations Population Division, New York, 1994. 
Abortion: Recourse to abortion: legal conditions, practices and frequency. Entre Nous, 22/23, pp. 8-9, 
June 1993.. Sexuality and Family Planning unit. WHO Regional Office for Europe. Unintended preg­
nanes: Cartwright. A. Unintended pregnancies that lead to babies. Social science and medicine, 27: 
249-254 (1988). And Fleissig. A. Unintended pregnancies and the use of contraception: changes from 
1984 to 1989. British medical Journal, 302 : 147 ( 1991 ). 
Aging: Population forecasts and dependency ratio. World population prospects. The 1992 revision. 
New York. United Nations, 1993. Female employment participation rates: health database, Paris, 
OECD: 1993. 
Migration: Eurostat. op. cit. 
74 
2.2 Life expectancy 
United Nations Development Programme. Human development report 1994. New York. Oxford 
University Press. 1994. And World Bank. op. cit. And Middellevetidsudvalget. Levetiden i Danmark. 
Copenhagen. Sundhedsministeriet. 1994. 
Fig. 2.2.2: The line drawn in the graph is only indicative. 
2.3 Inequalities 
For a bibliography on inequalities in health see: Whitehead, M. The concepts and principles of equity 
and health. Copenhagen. WHO Regional Office for Europe. 1990. Country-by-country descriptions are 
in a special issue "Health inequities in Europe" of Social science and medicine. 31(3): 223-420 (1990). 
See also: Power, C. Health and social inequality in Europe. British medical journal 308: 1153-1156 
(1994). And Fox, J., ed. Health inequalities in European countries. Aldershol. Ciower. 1989. For 
surveys showing symptoms in women and men see. for example. Smyth, M. & Browne. F. General 
household survey 1990. London. Office of Population Censuses and Surveys, 1992 (tables 4.7-4.10): 
and Ruwaard. D. et al. Public health status and forecasts: the health status of the Dutch population 
over the period 1950-2010. The Hague. Rijksinstituut voor Voiksgezondheid en Milieuhygiene. 1994. 
Fig. 2.3.1: the graphs show the ratios of male to female deaths, by age. at different periods 
during the century. Thus, in 1920-1924 male deaths exceeded female deaths most at age 50-60, 
but only by a factor of about 1.5 : 1. By 1960-1964 this ratio had increased considerably, and 
for the later periods the peak of excess mortality in young men - three times as many deaths 
in their mid-20s in 1985-1989 - is visible. 
Fig. 2.3.2: the data, from a study of health and social inequalities in the Federal Republic of 
Germany, are for men in "blue-collar" and "white-collar* pension funds. They do not indicate 
true expectation of life, as men who die before pensionable age are not included. The trend 
is different for women (see source). 
Fig. 2.3.3: this comparison over time should be treated cautiously, because the data are 
standardized for each decade rather than for a single year, and the occupational groups (and 
sizes) constituting the social classes were changing. 
Chapter 3. 
Patterns of disease and health-related behaviour 
Fig. 3.0.1: definition of causes by ICD9 code(s). Diseases of the circulatory system 390-359; 
External causes E800-E999: Cancer (Malignant neoplasms) 140-208; Congenital anomalies 
740-759: Ill-defined causes 780-799. 
Fig. 3.0.2: definition of causes by ICD9 code(s). Accidents includes all external causes (E800-
E999) except suicide (E950-E959) and homicide (E960-E969): Respiratory diseases 460-519; 
Lung cancer 162; Breast cancer 174; Heart (Ischaemic heart disease) 410-414; Stroke 
(Cerebrovascular diseases) 430-438: "Other cancer" and "Other CVD" defined as the residual 
within cancers and diseases of circulatory system (see notes to Fig. 3.0.1). This figure does not 
include the deaths of infants (aged less than 1 year). The main causes of infant mortality in 
EC are congenital anomalies, sudden deaths and certain conditions originating in the perinatal 
period. 
75 
3.1 Children 
Genetic screening: ethical issues. London. Nuffield Council on Bioethics. 1993. For handicap in very 
premature babies see Escobar. G.J. et al. Outcome among surviving very low birthweight infants: a 
meta-analysis. Archives of disease in childhood. 66: 204-211 ( 1991 ). And Johnson, A. et al. Functional 
abilities at age 4 years of children born before 29 weeks of gestation. British medical journal. 306: 
1715-1718 (1993). Child accidents see: European Home and Leisure Accident Surveillance System 
(EHLASSt: summary of data 198~-88 (Commission working document SPC/089/89. table 2). Cancer 
see: Coleman. M.P. et al. Trends in cancer incidence and mortality. Lyon. 1ARC Scientific 
Publications. 1993 (No. 121). 
Fig. 3.1.2: known numbers of thalassaemia major: Greece 1528: Italy 4475: UK 598. Of sickle 
cell disease: Greece 406: Italy 400: UK 3233 (see figure for source). 
Childhood infectious diseases: The rates (from country HFA reports) depend on notifications by 
doctors: they are an underestimate of true incidence but may be compared over time. Studies of 
immunization and outbreak investigation in EC countries, see: Guerin. N. EUREPI: research in 
methodologies of immunisation programmes management in Europe. In: Fracchia, G.N. & Theofilatou, 
M.. ed. Health services research. Amsterdam, IOS Press, 1993. And EUREPI final report 
(unpublished). EC paper "for box": COM(93) 246, 9 June 1994. 
3.2 Young people 
The WHO Cross-National Health Behaviour in School-Aged Children Study is currently analysing data 
from a fourth survey. It aims at representative samples of children, see Smith, C. et al. Health 
behaviour research with adolescents: a perspective from the WHO cross-national health behaviour in 
school-aged children study. Health promotion journal of Australia, 2(2): 41-44 (1992). Also The 
European Network of Health Promoting Schools. Copenhagen, WHO Regional Office for Europe. 
1993. Also Jones, E.F. Teenage pregnancy in industrialized countries. New Haven. Yale University 
Press. 1986. 
Fig. 3.2.3: The rate has been calculated for this report by taking the percentage of all women 
giving births who are aged less than 20 (HFA indicator 28.06.01) divided by the number of 
women aged 15-19 years in the population. 
Accidents: Data on deaths and injuries {from Statistics of road traffic accidents in Europe, vol XXXIX. 
Geneva. United Nations. Economic Commission for Europe, 1994) are collected by police and may 
differ slightly from WHO mortality data derived from death certificates. EHLASS, op. cit. 
Fig. 3.2.4: is derived from a large table of standard road accident statistics for England and 
Wales. Most accidents involve a combination of vehicles. The table records vehicle A. and 
pedestrians, here called the victim (who is hit), and vehicle B (here called the agent) which 
does the hitting. See source. 
Fig. 3.2.5: ICD9 code(s) E810-E819. 
Fig. 3.2.7: 1CD9 code(s) E960-E969. 
76 
3.3 Adults 
Cancers: Breast cancer: See Coleman. M.P. et al., op. cit. (this publication includes registry and 
country mortality data by cancer site for EC countries). 
Fig. 3.3.1: Main cancers from Parkin. D.M. et al. Cancer incidence in five continents, volume 
VI. Lyon. IARC Scientific Publications. 1992 (No. 120). Cancer registration is incomplete 
across EC countries; England and Wales is chosen as the largest published population, 
reflecting a northern patterm ,Varese province an established registry in a southern EC 
country. 
Fig. 3.3.2 and 3.3.3: ICD9 code(s) 162. 
Fig. 3.3.4: ICD9 code(s) 174. 
Fig. 3.3.5: ICD9 code(s) 151. 
Coronary heart disease: Sudden deaths and survival. Myocardial infarction community registers. 
Copenhagen, WHO Regional Office for Europe. 1979 (Public Health in Europe. No. 5). 
Fig 3.3.6: ICD9 code(s) 410-414 
Fig. 3.3.9: 1CD9 code(s) 430-438. 
Fig. 3.3.10. ICD9code(s) 571 
Chronic diseases: Studies supported by the European Commission include: Siiman. A. The 
epidemiology of vertebral osteoporosis in Europe: prevalence, risk factors and impact. 
In: Vuylsteek. K. &. Hallen. M. Epidemiology. Amsterdam, IOS Press. 1994 (168-181). And 
Fuller. J.H. The epidemiology and prevention of diabetes. In: Vuylsteek, K. & Hallen. M., op. cit. 
(140-167). j4w/Burney, P. Asthma prevalence and risk factors. In: Vuylsteek. K. & Hallen, M. op. cit. 
(241-251). And Hauser. W.A. et al. Incidence of epilepsy and unprovoked seizures in Rochester, 
Minnesota, 1935-1984. Epilepsia. 34(3): 453-468 (1993). Also Williams, R et al., ed. Diabetes in 
Europe. London, Libbey, 1994. 
Occupational diseases: Commission of the European Communities. Directorate-general of 
Employment, Industrial Relations and Social Affairs. European social policy: options for the Union. 
(Green Paper). Section C.6(a) - health and safety at work. Luxembourg. Office for Official 
Publications of the European Communities. 1994. EUROSTAT. Disabled persons: statistical data. 
Volumes 1 and 2. Luxembourg, Office for Official Publications of the European Communities 1991. 
Salud u ambiente de trabajo en Barcelona. Barcelona, Ajuntament de Barcelona, 1993. And Lifestyle 
and health risks at the workplace. Copenhagen, WHO Regional Office for Europe, 1993 (European 
Occupational Health Series, No. 2). 
Fig. 3.3.12: collection of these data has not been standardized between countries. 
77 
Infections: HIV/AIDS. Data collected by the European Centre for the Epidemiological Monitoring of 
AIDS. Hôpital national de Saint-Maurice. 94410 Saint-Maurice. France, available as quarterly reports. 
And F. Dubois-Arber & Paccaud. F. Assessing A1DS/H1V prevention: What do we know in Europe? 
Social and Préventive Medicine. 39. SUppl.l. (1994). Vivre en Europe: Lu santé en Europe. Institut 
international d'administration publique. 1994. Foodbome infections: WHO Surveillance programme 
for control offoodborne infections and intoxications in Europe. Fifth report 1985-89. Berlin. Institute 
of Veterinary Medicine. Robert von Ostertag Institute, 1992. 
Mental health: Prevalence estimates depend on methods and samples. Sec Burvill. P.W. The 
epidemiology of psychological disorders in general medical settings. In Sartorius. N. et al., ed. 
Psychological disorders in general medical settings. Toronto. Hogrelc &. Huber. 1990. Also 
Lehtinen. V. et al. The prevalence of PSE-CATEGO disorders in a Finnish adult population cohort. 
Social psychiatry and psychiatric epidemiology, 25: 187-92 (1990): table 1. Also Farta. J.G.S. The 
WHO health targets for Europe and psycmatric epidemiology. Paper presented at the Congress of the 
International Federation for Psychiatric Epidemiology. Lisbon. 14-17 April 1993. Suicide, medical care: 
see Barraclough, B.M. et al. A hundred cases of suicide: clinical aspects. British journal of psychiatry. 
125: 355-373^(1974). 
Fig. 3.3.17: ICD9 code(s) E950-E959 
Fig. 3.3.18: These data represent individual towns and are not national figures. The data are 
also unstandardized for age, and may be revised as the study progresses. 
3.4 Older age 
Disability in EU countries: sum of data by country in EUROSTAT, 1991 (op. cit.) And Mulier, I. 
Country profiles on oral health in Europe 1991. Copenhagen, WHO Regional Office for Europe, 1991. 
And Hofman et al. The prevalence of dementia in Europe. International journal of epidemiology, 20(3): 
736-748 ( 1991 ): table 4. And Age and attitudes: main results from a Eurobaromeler survey. Brussels, 
CEC DGV. 1993. And A European community health policy for older people. London, Eurolik Age, 
1993. And Heikkinen. E. et al., ed. The elderly in 11 countries: a socio-economic survey. Copenhagen, 
WHO Regional Office for Europe, 1983. 
78 
Chapter 4. 
The determinants of health 
4.1 Health-related behaviour 
Smoking: information from: WHO Tobacco or Health Database. And Peto. R. et'al. Mortality from 
tobacco in developed countries: indirect estimation from national vital statistics. Lancet. 339: 1268-
1278 (1992). (Peto et al. extrapolate US data, showing "half of all regular smokers would be killed 
by their habit" to other countries including the EC.Mm/Commission of the European Communities. 
Directorate-general of Employment. Industrial Relations and Social Affairs (V/E/l ). And Europe against 
cancer: background file for the evaluation of the first five years of execution of the programme 1987-
91. D: summan, of the EURO health survey. Brussels. DGV (internal document) 1992. And Europe 
against cancer: second action plan 1990-1994. Brussels, Commission of the European Communities. 
1990. Passive smoking: see No smoke between us. Brussels, BASP, 1993. 
Fig. 4.1.1: These data were collected in a EUROBAROMETER survey, sampling 12 500 
people age 15+ in February - March 1992. 
Fig. 4.1.4: National alcohol consumption in litres of pure alcohol per capita per year, which 
is consumed in different beverages according to national customs. 
Drug misuse:. Hartnoll. R. (on behalf of the European Monitoring Centre on Drugs and Drug 
Addiction). Epidemiological research on illicit drugs in Europe. Final report. Institut Municipal 
d'Investigacio Mèdica. Barcelona, 1993. Tenth Ministerial conference of the Pompidou Group. 
National reports. Strasbourg. Council of Europe, 1994. Also Paris, Baromètre santé 92. Comité français 
d'éducation pour la santé. 1994. And Gutiérrez-Fisac, J.L. et al. Health indicators (period 1990-91). 
Madrid. Ministeriö de Sanidad y Consumo: Secretaria General de Salud, 1993. 
Fig. 4.1.3: Own calculations. Indices of general price levels has been provided by Eurostat/B3 
Fig. 4.1.6: The data should be interpreted cautiously as there have been changing awareness 
and patterns of recording. 
Nutrition: Current etiological studies are coordinated under EURONUT Concerted Action of DGXII. 
See Hautvast. J.G.A.J. Nutrition and health in the European Community. In: Vuylsteek, K. &. Hallen, 
M., ed. op. cit. (298-331). Food balance measurement see: Becker, W. & Helsing, E. Food and health 
data: their use in nutrition policy-making. Copenhagen, WHO Regional Office for Europe, 1991 (WHO 
Regional Publications. European Series, No. 34) And James, W.P.T. etal. Healthy nutrition: preventing 
nutrition-related disorders in Europe. Copenhagen, WHO Regional Office for Europe, 1988 (WHO 
Regional Publications. European Series, No. 24). 
Fig. 4.1.7: Body mass index, defined as a person's weight divided by the square of their 
height, is closely related to skin-fold thickness and thus obesity. Values over 26 kg/sq m are 
regarded as overweight. 30+ very overweight. 
Fig. 4.1.8: Country food balance data are reported in a standard form to the UN Food and 
Agricuitural Organisation. They reflect the balance between production, imports, exports, 
consumption and waste. They are useful as indicators over time. 
79 
Exercise: Blair. S.N. et al. Physical fitness and all-cause mortality. Journal of the American Medical 
Association. 262(17): 2395-2401 (1989). Also: Koplan. J.P. et al. Physical activity, physical fitness, 
and health: time to act. Journal of the American Medical Association. 262: 2437 (1989). And British 
Medical Association. Cycling: towards health and safety. Oxford. Oxford University Press. 1992. 
4.2 Environment and health 
Environment: Concern for Europe's tomorrow: health and environment in the WHO European 
Region. Copenhagen, WHO Regional Office for Europe, 1994. Also Europe s environment: the Dohris 
assessment and Europe s environment: statistical compendium for the Dohris assessment. Luxembourg. 
Office for Official Publications of the European Community, 1995 (in press) 
Housing: For a broader definition of poor housing, see Avramov. D. Homelessness: a condition of a 
social process? Brussels. FEANTSA (Federation Européenne d'Associations Nationales Travaillant 
avec les Sans-Abri ). 1994 (17-18). (Estimates based on data from Statistics on housing in the European 
Community, dwellings which do not meet criteria of good quality in 10 EC countries (data not available 
for Germany and Greece). Brussels. CEC DGV, 1993, (39). Also Bellerman. M. et al. Soàial exclusion 
in the Federal Republic of Germany. European Economic Interest Group "Animation & Research", 
Lille. 1993. 
Homelessness: Daly. M. The right to a home, the right to a future. Third report of the European 
Observatory on Homelessness, Brussels. FEANTSA, 1994. (This estimate uses approximately similar 
definitions, of people without accommodation or using short-term lodgings but modes of reporting and 
enumeration van' considerably between countries; homelessness is probably underreported in official 
data in southern EC countries.) 
Transport: Transport and Health Study Group. Health on the move. Birmingham, Public Health 
Alliance. 1991. British Medical Association. 1992 (op. cit.). Children travelling to school ill Britain: 
Hillman. M.. ed. Children, transport and the quality of life. London, Policy Studies Institute, 1993 
(chapter 3. Fig. 2). European Sustainable Cities, first report October 1994 of the EU Expert Group 
On The Urban Environment Sustainable Cities Project, Brussels, CEC DGX1, 822/94 
Fig. 4.2.6: This figure is derived from data in the source paper; the data are not standardized 
for other coronary risk factors. 
Access: A report commissioned by the Directorate-General for Transport estimates that "up to 52 
million people in Europe will have some degree of difficulty using public transport at any one time". 
In: Transport information for people with disabilities; Summary and recommendations. Research 
Institute for Consumer Affairs. 1992. Also European Conference of Ministers of Transport. Transport 
for people with mobility handicaps: policy and achievements in Europe. Paris, OECD, 1991. 
Noise: Europe's Environment 1993 Noise Pollution, report for the European Environment Agency, 
January 1994 
Air, water, waste, radiation: See The state of the environment in the European Community. Brussels, 
Commission of the European Community, 1992 (COM(92) 23, chapter 4) and the Dobris report and 
statistical compendium, cited above. 
80 
4.3 Social concerns 
Unemployment: data from Commission of the European Communities. Directorate-general of 
Employment. Industrial Relations and Social Affairs. Growth, competitiveness, employment: the 
challenges and ways forward into the 21st century (White paper). Luxembourg, Office for Official 
Publications of the European Communities. 1993 (44). 
Poverty: EUROSTAT. La pauvreté en chiffres: l'Europe au début des années 80. Luxembourg. Office 
des publications des Communautés européennes. 1990. And EUROSTAT. Analysing poverty in the 
European Community: policy issues, research options and data sources. (Eurostat news, special 
edition). Luxembourg. Office for Official Publications of the European Communities. 1993. 
Commission of the European Communities. Directorate-general of Employment. Industrial Relations 
and Social Affairs. European social policy: options for the future. Luxembourg, Office for Official 
Publications of the European Communities, 1993. 
4.4 Health services 
Country health systems: Commission of the European Communities. Directorate-general of 
Employment. Industrial Relations and Social Affairs. Social protection in Europe. Luxembourg, Office 
for Official Publications of the European Communities, 1994 (chapter 7 on health care systems). And 
Berthod-Wurmser, M. La santé en Europe. Paris. La documentation française, 1994. And Schneider, 
M. et al. Health care in the EC member states. Health policy. 20(1): 1-251 (1992). 
Health promotion and prevention: Duplessis, P. Public health and industrialized countries. Québec. 
Les Editions du Québec, 1989. And Dekker. E. & van der Werff. A. Policies for health in European 
countries with pluralistic systems. Houten, Bonn Stafley Van Loghum, 1990. 
Patterns of care: The data are from: OECD health systems: facts and trends 1960-91. Paris. OECD, 
1993 (Health policy studies No 3. vols 1 and 2). Also mental health: Mangen. S.P., ed) Mental health 
care in the European Community. London. Croom Helm. 1985. And King. D. Moving on from mental 
hospitals to community care: a case study of change in Exeter. London, Nuffield Provincial Hospitals 
Trust. 1991. And Breemer ter Stege, C.P.C. & Gittleman, M. Trends in mental health care in western 
Europe in the past 25 years. International journal of mental health, 16(1-2): 3-243 (1987). 
Pharmaceuticals: Commission of the European Communities. Report on the operation of the 
Committee for Proprietary Medicinal Products in 1991 and 1992 (Commission working paper SEC(93) 
771 ). 1993. And The rules governing medicinal products for human use in the European Community. 
(Commission internal document III/5826/93-EN.) And Biotechnology; Directorate-general of 
Employment. Industrial Relations and Social Affairs. Growth, competitiveness, employment: the 
challenges and ways forward into the 21st century (White paper). Luxembourg. Office for Official 
Publications of the European Communities, 1993 (pp. 100-101). And Commission of the European 
Communities. On the outlines of an industrial policy for the pharmaceutical sector in the European 
Community. Brussels 1994 (COM(93) 718 final). 
Fig. 4.4.1: Own calculations. Price indices of a basket of pharmaceuticals published by the 
Commission in COM(93) 718 originate from a survey carried out by ABDA. This survey was 
a replication of a survey carried out by REU^ (Pclgian Consumers Association) in 1987. 
Eurostat/B3 has provided data on the general consumer price levels in 1992 which has been 
used as a proxy for 1993 price levels. 
81 
Quality: see also: Holland. W.W. EC working group on health services and "avoidable deaths" (pp. 
16-31 ) and Berrino.' I . EUROCARE. Cancer registries-based study on survival and care of cancer 
patients in Europe (pp. 420-427) //;: Fracchia. G.N. &. Theofilatou. M., ed. Health services research. 
Amsterdam, lOS Press. 1994. 
Fig. 4.4.3: These data are from local registries and may not reflect national differences. 
Research: De Moor. G. et al. Telematics for health care. Its impact? Its future? Luxembourg. 
Commissionof the European Union, Directorate General XIII, Unit C4. 1994. And Roger France. F.H. 
& Laires. M.. ed. Results of the study on * Communication of health care resource management data 
in Europe". Luxembourg, Commission of the European Union. Directorate General XIII, 1994. And 
Laredo, P. et al. The research networks built by the MHR4 programme. Luxembourg, Commission of 
the European Communities, Directorate-General for Information. Technologies and Industries, and 
Telecommunicate ns. 1992. And Research and technology development on telematic systems in health 
care (AIM programme). Luxembourg, Commission of the European Communities, DGXIII Unit C4. 
1993. And Ecosystems Research Report 15. A Review of Research in Environmental Health & 
Chemical Safety, In The Step (1989-92) & Environment (1991/94) Research Programmes. Report EUR 
15909 EN, Commission of the European Communities. And EPHA conference on research priorities 
for public health in Europe. Brussels, EPHA, 1994. 
Fig. 4.4.5: Data from Commission of the European Communities DGXII/E. 
82 

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