The case for integrating health into Article 6 of the EC treaty

Gaudenz Silberschmidt of the International Society of Doctors for the Environment believes changes should be made to the European Community Treaty to ensure health has a higher profile in the achievement of sustainable development at the European level. He calls for "Health Integration" so that health considerations would be given the same status as environmental protection in all areas of EU policy making.

"Sustainable development" appears at the beginning of Article 2 of the Treaty establishing the European Community. The strategy for achieving sustainable development was adopted at the Gothenburg summit in June 2001 by the European Council. The time has now come to protect health directly through all European economic, social and environmental policies. Therefore Article 6 of the Amsterdam Treaty, which calls for integration of environment considerations into all sectoral policies, should be amended to include a similar provision for health.

The concept of "integration"

Traditionally, sectoral policies of the European Community are dealt with separately. The economic sector promotes economic growth, the agricultural sector promotes agricultural production and so on. However, all policies influence other sectors and the shortcomings of such a division of tasks is becoming increasingly clear.

The linkages between different sectors are most obvious for the "corrective" policy areas, such as environment, health or social policies, which aim to deal with the "side effects" of other policy areas. As a result of the acceptance of the need to "correct" policy for environmental considerations, a specific article on environmental policy integration was made in 1997 in the Amsterdam revision of the EC treaty.

Article 6

Environmental protection requirements must be integrated into the definition and implementation of the Community policies and activities referred to in Article 3, in particular with a view to promoting sustainable development.

Since then, the European Council has launched the Cardiff process whereby one sector after another is requested to report on efforts to integrate environmental considerations into their policies. This means that not only is the environment ministry or directorate responsible for the environment but also each sector has become responsible for environmental performance.

Health and its determinants

Although health is not defined as one of the three central components of sustainable development, it can be seen as central to economic, environmental and social development. The WHO defines health as "an integral state of physical, mental and social well-being and not just the mere absence of disease." Thus, there cannot be good health in an unhealthy environment.

Estimates suggests that the environment determines 20-33% of the health status of a population, compared with 40-50% for socio-economic and behavioural factors, 20-30% for genetic predisposition and 10-15% for the health care system. (1) In other words, most of the determinants of population health lie outside the influence of the health sector and the health authorities. Therefore, to be successful, a real health policy must be a policy of health integration just as much as environment policy needs to be environmental integration policy.

In legal terms health is often seen as the "normal" status which can be damaged by external risk factors, such as smoking or accidents. However, this is only partially true. Ill health is as often linked to the lack of essential health promoting factors, such as lack of physical exercise due to the transport system, as it is to the undesirable presence of a health-damaging factor, such as tobacco consumption. While a health damaging factor can relatively easily be attributed to a responsible cause, the lack of another factor can only be addressed through an integrated policy approach.

Competence in health

The current competence of the EU in the field of health are described in Art. 3.1p and 152 of the EC treaty. They read as follows:

Art. 3.1 For the purposes set out in Article 2, the activities of the Community shall include, as provided in this Treaty and in accordance with the timetable set out therein: (…)

(p) a contribution to the attainment of a high level of health protection; (to be compared with Art. 3.1 (l) a policy in the sphere of the environment; and Art. 3.1 (b) a common commercial policy;)

TITLE XIII: PUBLIC HEALTH

5. Community action in the field of public health shall fully respect the responsibilities of the Member States for the organisation and delivery of health services and medical care. (…)

Making a very clear distinction between public health and health care is crucial. As described above, only 10-15% of the health status of a population depends on the provision of health care. The main determinants of health are factors outside the health system - and often outside of the influence of health authorities.

For traditional and subsidiarity reasons, social security and the health care system have always remained within the competence of the EU member states. European institutions have had very little influence. The call for a health integration provision, followed by a health integration process, would not interfere with the distribution of health care competence between the EU and its members. Health integration deals mainly or even exclusively with health determinants outside the health sector. It may be necessary to make the distinction between integration of health determinants outside the health care sector explicit in a revised text of the EC Treaty. The question of the distribution of competence between the EC and its Members States on health care services should be addressed separately.

Starting the process

In order to engage in a process of health integration as strong as the Cardiff process on environmental policy integration, Article 6 of the EC Treaty should be amended at the next treaty revision as follows:

"Environmental protection and health requirements must be integrated into the definition and implementation of the Community policies and activities referred to in Article 3, in particular with a view to promoting sustainable development."

There are many examples that highlight the need for health integration:

 Tobacco consumption should be influenced by educational policies, fiscal policies (cigarette prices), agricultural policies (phasing out of tobacco subsidies) and economic policies (prohibition of advertisement), etc.

 Poverty-related health problems depend directly on economic and social policies, which should consider health not only implicitly but explicitly.

 Air pollution depends on fiscal policy. Several countries are currently selling diesel significantly cheaper than gasoline. This is favoured by environmentalists because it produces lower CO2 emissions. However, diesel engines produce about 100 times more PM10 dust particles than comparable gasoline engines. Most dust particles are trapped in nasal hair. But PM10 particulates are so small that they penetrate the lungs with harmful consequences for the respiratory system. Environmental policy therefore also needs to integrate health aspects because promoting diesel because of its lower CO2 emissions overlooks the threat to health from the higher tiny dust particle (PM10) emissions.

 The epidemic of "sedentarism", or the lack of physical exercise, can only be tackled by adaptations of the transport policy combined with educational efforts.

 The composition of the diet is linked to, and influenced by, agricultural policy.

Combining environment and health policy integration

It might be tempting to suggest two separate integration processes - one for environment and one for health. However, the environment is an important determinant of health. It would be difficult to decide which aspects should be dealt with in the context of environment integration and which as health integration. For example, transport policy affects landscape fragmentation, with environmental consequences.

However, the same policy also affects health, in that it has a bearing on the lack of opportunities for physical exercise and the potential accident toll. Transport questions also affect noise, air pollution, greenhouse gas emissions and so on, all of which are relevant both for the environment and for health. In agricultural policy, too, it would be useful to consider environmental and health considerations together. For example, pesticide use has implications for both environment and health.

The process of environmental policy integration does not automatically include health. Areas of common interest exist where the involvement of health authorities and health experts will strengthen the environmental arguments for environmental changes needed. However, many policy areas affecting health (such as tobacco advertising for example) are simply not touched upon by environmental policy integration. Now is the time to begin giving health considerations the attention they deserve.

The International Society of Doctors for the Environment (ISDE) is an international environment and health NGO of medical doctors with member organisations in 40 countries and bringing together 30,000 individuals.

References:

(1) K.R. Smith, C.F. Corvalan & T. Kjellström, How much global health is attributable to environmental factors? Epidemiology 10(5), 573-584, 1999 & May A. (Quoting Jo Ivey Boufford Principal Assistant secretary for Health in the US Department of Health and Human Services) in Forward Thinking- Health Service J. 1996. p.21 & Bernhard Badura, in "Scientific foundations for a public health policy in Europe" (Juventa, Weinheim, 1995, p.364)

Info:

Gaudenz Silberschmidt MD MA, Executive director

ISDE

Le Chateau

CH-1374 Corcelles-sur-Chavornay, Switzerland

Tel: +41 24 441 56 50, Fax: +41 24 441 56 51

E-mail: gs@isde.org

Internet: http://www.isde.org