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Regional Committee decisions
The World Health Organization (WHO) Regional Committee for the Eastern Mediterranean is WHO’s decision-making
body in the Eastern Mediterranean Region. It meets annually with representation from all Member States of the Region.
A main function of the Committee is to formulate policies and strategies that provide Member States with guidance
on action that needs to be taken to promote and protect health in the Region. This section, Regional Committee Decisions, serves to highlight selected resolutions and decisions of the Committee to inform and update readers of the key
actions related to the regional health priorities to be undertaken by countries and WHO.
Regional health and environment strategy and framework for
action in the Eastern Mediterranean Region, 2014–2019
Introduction
The sixtieth session of the World Health Organization
(WHO) Regional Committee for the Eastern Mediterranean
endorsed (in October 2013) a new regional strategy on
health and the environment with a framework for action
during 2014–2019 (1). The strategy provides a roadmap
for protecting health from environmental risks in the
Eastern Mediterranean Region (EMR). This paper summarizes the key themes, including pertinent environmental
health pressures, states and responses described in the
strategy.
Environmental determinants of health are responsible
for about 24% of the burden of disease, leading to more
than 1 million deaths and 38 million disability-adjusted life
years (DALYs) lost each year in the EMR (2). In economic
terms, this DALYs loss can be translated into an estimated
annual loss of US$ 144 billion (based on a very conservative assumption, this equals the gross domestic product
of Member States in the Region for one year). Despite
the variable impacts and differing health consequences, all
countries are adversely affected by the risks of environmental pollution and ecological deterioration. Such risks are aggravated by the onset of climate change and unsustainable
development.
The enormity of the environment-related burden of
disease means that these exposures and related health risks
cannot be addressed effectively if they are addressed separately. It is essential to adopt an integrated ecological public
health approach which recognizes the complex interactions
between biological, behavioural, environmental and social
factors. For such a multisectoral approach to work, the role
and mandate of ministries of health and other government
sectors need to be revisited.
The evidence linking environmental risks with communicable diseases is well established historically. Action
to tackle these factors is cost-effective and can result in
major reductions in morbidity and mortality associated
with waterborne, foodborne, and vector-borne diseases.
Evidence linking environmental risks to noncommunicable
diseases and injuries is also emerging rapidly. For example,
19% of all cancers (3) and 16% of all cardiovascular diseases
(4) have been attributable to the environment. Action to
manage these risks is cost-effective and can result in major
reductions in the burden of disease associated with air
pollution, chemical toxins, radiation, hazardous wastes and
traffic accidents
The priorities and strategic directions set out in the
EMR regional strategy on health and the environment
are based on the magnitude of the problem, the current
scientific evidence and justification for suggested interventions, the expressed demand from countries for appropriate
interventions, and the binding international and regional
framework agreements already in place. Rigorous review of
evidence and expert consensus were employed systematically in developing the strategy. It takes into account and is
aligned with the priorities identified by countries in the
WHO Country Cooperation Strategy (5), as well as the
recommendations of two regional consultations, held in
June 2011 and November 2012.
Strategic framework
Many aspects of environmental health services are outside
the mandate of a single agency. Therefore, it is essential that
a collaborative multi-agency approach is adopted, emphasizing the leadership of the health sector in terms of governance
and surveillance responsibilities, as well as advocacy and
Acknowledgement: This report on the regional health and environment strategy and framework for action was prepared by Ahmad Basel AlYousfi, Director, and Mazen Malkawi, Technical Officer, World Health Organization Centre of Environmental Health Action, Amman, Jordan.
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Table 1 Total deaths attributable to environmental factors per 100 000 population in countries of the Eastern Mediterranean
Region (EMR)
Country
Deaths per
100 000
Country
Afghanistan
748
Pakistan
Somalia
603
Iraq
316
Sudan
Deaths per
100 000
Country
Deaths per
100 000
196
Morocco
106
Lebanon
132
Saudi Arabia
Tunisia
124
Libya
256
Egypt
117
Jordan
83
Djibouti
255
Islamic
Republic of Iran
113
Syrian Arab
Republic
72
Yemen
247
Country
Deaths per
100 000
Bahrain
58
91
Oman
55
85
Kuwait
33
UAE
33
Qatar
32
Source: Data extracted from the WHO Global Burden of Disease, 2008 update.
motivation of other specialized environmental health service
agencies. Keeping this in mind, the new strategy guides
WHO and countries of the EMR to adopt the following
strategic directions:
• enhancing the capacity of the health sector to evaluate,
monitor, regulate and manage environmental risks;
• strengthening the advocacy, partnership building and leadership roles of the health sector for mobilizing resources
and synergizing actions of pertinent sectors and providers
of environmental health services;
• equipping the health sector with environmental norms and
assessment tools for catalysing stakeholders to integrate
health protection measures into their development processes.
Environmental health situation in the EMR
The countries of the EMR differ greatly in terms of their
socioeconomic, demographic, environmental and health
conditions. Tables 1 and 2 provide a good example of
this diversity in terms of environmental impacts. Three
groups of countries can be defined. Group 1 including
high-income countries with good environmental health
services; group 2 includes middle-income countries with
“endeavouring” environmental health services; and group
3 countries include low-income countries with poor and
lacking environmental health services. While the health
impacts of environmental deterioration are mostly manifested in high communicable disease prevalence in group 3
countries, a clear transition in the impact of environmental
risks is depicted in group 1 and 2 countries, where environmental deterioration is shifting in trend from affecting
communicable disease to affecting noncommunicable
disease prevalence.
Key environmental health priorities in EMR
In light of the burden of disease analysis, the country cooperation strategies and the expressed needs of countries, seven
technical areas of work are recommended as priorities in the
strategy. These areas are: water and sanitation, air quality,
chemical safety, waste management, emergencies, climate
change and sustainable development. The following sections
describe the overall situation of these priorities in the EMR,
and the recommended strategic actions by WHO and
countries of the Region.
Water and sanitation
Domestic water availability has declined steadily as a result
of water scarcity and is aggravated by climate change and
population growth. Many water supply systems in the EMR
Table 2 Environmental health groupings of countries of the Eastern Mediterranean Region (EMR)
Variable
Group 2
Group 3
Income group
High
Middle
Low
Level of environmental health
services
Good
Endeavouring
Lacking
EMR population (%)
7
44
49
25.4
39.3
94.4
Air pollution
Injury risk factors
Chemicals
Water and sanitation
Air pollution
Chemicals and wastes
Water and sanitation
Indoor air pollution
Chemicals and wastes
Burden of disease
(DALYs per 1000 capita per year)
Priority environmental risk factors
DALYs = disability-adjusted life years.
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Group 1
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Table 3 Percentage of population of selected countries of
the Eastern Mediterranean Region with access to water and
sanitation
Country
% with access to:
Water
Afghanistan
Djibouti
Sanitation
39
72
8
39
Iraq
15
16
Morocco
18
30
Pakistan
9
53
Somalia
70
76
Sudan
45
76
Yemen
45
47
Source: WHO/UNICEF Progress on sanitation and drinking-water: 2013 update
(6).
experience interruptions, exposing the population to health
threats due to lack of water safety safeguards. The 2012
WHO/UNICEF Joint Monitoring Programme on the Water and Sanitation Sector indicated that all group 3 countries
and some countries in group 2 are not on track to achieve the
targets of Millennium Development Goal 7 relating to water
and sanitation (6). Of the populations of countries listed in
Table 3, between 8% and 70% remain without improved access to water and between 16% and 76% without improved
access to sanitation.
In response to this chronic challenge, the strategy proposes action by WHO and countries of the EMR to: monitor the performance of the health outcomes of the water and
sanitation sector; generate evidence-based guidance and
health-based targets; strengthen the regulatory and surveillance roles of the health sector pertinent to the water and
sanitation systems; and strengthen the capacity to conduct
strategic reviews, delineation and operationalization of best
policies and programme options in the areas of water and
wastewater quality and safety.
Air quality
WHO estimates that in each year, indoor and outdoor air
pollution kill about 145 000 and 117 000 people respectively
in the EMR (7). Most of the deaths due to indoor pollution occur in group 3 countries, where about 170 million
people still burn solid fuels for cooking and heating (based
on data extracted from the Global Health Observatory on
the percentage of populations burning solid fuels in 2010)
(Table 4). While further research is needed to investigate
the magnitude of the problem, recent reports have revealed
that, because of increases in clean fuel prices, the use of dirty
fuels for cooking and heating is increasing. The major sources
of indoor air pollution in group 2 and 3 countries are environmental tobacco smoke, building materials and heating
practices. Unlike indoor air pollution, outdoor air pollutants
have impact on all three groups of countries. The major
sources of outdoor air pollution in the EMR are traffic and
industrial air emissions, and sand and dust storms, which are
aggravated by climate change. Recent estimates published
by the Institute for Health Metrics and Evaluation in 2012
indicate that the health impact of air pollution is much larger
than the current estimates suggest (8).
The strategy calls for action by WHO and countries to:
strengthen the regulatory capacity and partnership building
roles of the health sector for establishing and monitoring
national air quality standards in line with WHO air quality
norms; develop/strengthen the surveillance function of the
health sector with regard to air quality; and increase the
awareness of all stakeholders (including the public) about
air pollution risks.
Chemical safety
Based on the few chemicals for which data are available an
estimated 8.3% of global deaths and 5.7% of global DALYs
are attributable to exposure to chemicals (9). This is likely
to be an underestimate of the actual burden and includes
estimates from the following sources: chemicals involved
Table 4 Deaths attributable to air pollution per 100 000
population in the countries of the Eastern Mediterranean
Region
Country
Deaths per 100 000
Indoor
pollution
Afghanistan
Outdoor
pollution
228
3.74
Bahrain
0
0.00
Djibouti
6
3.90
Egypt
1
0.25
Iran, Islamic Republic
0
0.49
Iraq
2
1.83
Jordan
0
0.41
Kuwait
0
0.03
Lebanon
0
0.05
Libya
1
0.32
Morocco
2
0.59
0
0.07
35
2.86
Oman
Pakistan
Qatar
0
0.08
Saudi Arabia
0
0.25
139
3.53
37
1.49
Syrian Arab Republic
4
0.21
Tunisia
1
0.08
Somalia
Sudan
UAE
Yemen
0
0.04
33
0.82
Source: WHO Global Health Observatory data repository (11).
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in unintentional acute poisonings; chemicals involved
in unintentional occupational poisonings; pesticides involved in self-inflicted injuries; asbestos; occupational lung
carcinogens; occupational leukaemogens; occupational
particulates; outdoor air pollutants; indoor air pollutants
from solid fuel combustion; second-hand smoke; lead; and
arsenic in drinking water. Although estimates are not available at the regional level, there is sufficient reason to believe
that the same trend is valid for the EMR since production
and exposure to chemicals are increasing. It is estimated
that production of chemicals in the Region will increase by
40% in 2020 (9).
Several challenges face the countries of the Region,
particularly the low-income countries: lack of public awareness and of a culture of safety with regard to handling chemicals; lack of up-to-date databases and experienced human
resources to carry out risk assessment of chemicals; lack
of legislative frameworks and enforcement mechanisms;
overlapping mandates and responsibilities; and lack of
international financial mechanisms for multilateral environmental agreements.
Sound management of chemicals and strengthening
of national capacities for management of chemicals to
protect health will require major investment, as well as the
development of new practical techniques for chemical safety.
Several objectives are suggested by the strategy including:
integrating sound management of chemicals into national
health programmes; developing regional and national integrated health and environment monitoring and surveillance systems for chemicals; expanding and disseminating
international assessment of chemical risks to countries of
the EMR; and harmonizing the classification and labelling
of chemicals.
Waste management
Only a few countries in EMR, such as the member states of
the Gulf Cooperation Council, have already constructed
treatment, storage and disposal facilities for hazardous
wastes. The majority of countries in the Region lack the
technological capacity and financial means to build such
sophisticated systems. In the absence of such facilities, and
exacerbated by weak regulatory enforcement as well as
inadequate regional and international cooperation, wastes of
all types will continue to be a serious environmental health
challenge in the EMR.
Of special concern to WHO is the safe management and
disposal of health-care wastes. Countries of the EMR have
recently started to pay adequate attention to the proper management of such waste materials. Group 1 countries have
initiated effective health care waste management strategies,
group 2 countries mostly meet the minimum requirements
for proper management, and group 3 countries have not yet
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begun to implement adequate management of such waste
materials.
Given the diverse mixtures of toxic substances, microbial agents and harmful compounds embedded within waste
streams, the risk of adverse health exposures throughout the
waste management cycle is very high. The role of national
health authorities in the Region must be concentrated on
the health aspects of integrated waste management through:
strengthening national capabilities and capacities for management of wastes, focusing on the health implications of
wastes management; and minimizing health risks associated
with exposure to health-care wastes.
Environmental health management in emergencies
More than half of the countries of EMR are currently suffering from acute or chronic crises. Of the 33 countries that
were in health crisis in recent years 13 belong to our Region.
Climate change, globalization and rapid urbanization are
likely to expose populations to more frequent and complex
disasters. The number of refugees and displaced people
fleeing complex emergencies in the EMR is increasing. Most
of these people are displaced in countries in groups 2 and 3,
which already suffer from weaknesses in their environmental
health systems, and many of which are not yet prepared to
respond to the additional burden.
A systematic approach to addressing the environmental
health aspects of emergencies requires all countries to
invest in vulnerability and risk assessment and preparedness. This should include: assessing environmental health
risks and vulnerabilities in countries susceptible to crisis
improve capacities to effectively manage the environmental
health aspects of emergencies; leading the water and sanitation response activities within health-care facilities during
emergencies; and protecting health from environmental
risks throughout all phases of the disaster/emergency
management cycle.
Climate change
All countries of the EMR are observing environmental
changes, among them increases in temperature, heat waves,
reductions in rainfall, decline in productivity of crops and in
food security, decline in air quality and increases in frequency
of dust storms. WHO estimates that the Region is the
second most affected in the world after the African Region.
The health effects of climate change include: death and
injuries due to heat waves and extreme weather events, and
changing disease patterns, including increase in waterborne,
foodborne and vector-borne diseases, malnutrition, respiratory diseases and asthma. The EMR already faces numerous
emergency and humanitarian crises, and climate change is
likely to aggravate these situations (10). However, further
research is needed to assess the health impact of climatic
change in the Region.
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Table 5 Eastern Mediterranean regional strategy on health and the environment 2014–19: targets and indicators
Priority
Water and sanitation
Air quality
Waste management
Chemical safety
Indicator
Baseline in
2014
No. of countries participating in GLAAS
8
15
No. of countries actively verifying JMP profiles
15
22
No. of countries with updated drinking water quality standards
15
20
No. of countries adopting water safety plans
7
12
No. of countries with updated wastewater reuse standards
7
12
No. of countries that are reporting particulate matter data to the WHO
Global Database
8
15
No. of studies on burden of air pollution on health
0
6
No. of countries with ambient air quality early-warning systems
1
3
No. of countries that assessed environmental health services in their
health-care facilities
6
12
No. of countries with 50% of health-care facilities meeting WHO
essential standards on environmental health services in health-care
facilities
6
12
No. of countries that assessed the public health impacts of waste
management policies
0
6
No. of countries with public health strategies on SAICM
0
5
45
85
No. of countries covered by functional information poison centre
services
11
15
No. of countries with environmental health in emergency profiles
0
6
Functional network exists for environmental health emergency experts
and institutions (no = 0; yes = 1)
0
1
50
90
No. of countries with adaptation frameworks on health and climate
change
7
13
No. of countries with vulnerability assessment and adaptation strategies
on health adaptation to climate change
2
7
No. of countries incorporating climate data into national health
information systems
1
4
No. of countries integrating public health in sustainable development
policies as per Rio+20
0
3
No. of countries with programmes on Greening the Health Sector
0
3
% of countries with capacity developed to deal with chemical events
under IHR implementation
Environmental health
in emergencies
% of emergencies adequately responded to with integrated
environmental health services
Climate change and
health
Sustainable
development
Target in
2019
GLAAS = Global Analysis and Assessment of Sanitation and Drinking-Water; JMP = WHO/UNICEF Joint Monitoring Programme; SAICM = Strategic Approach to
International Chemicals Management; IHR = international health regulations; Rio+20 = United Nations Conference on Sustainable Development in Rio de Janeiro,
Brazil, 2012.
An integrated multisectoral approach to managing the
adverse health effects of climate change is already started
through a regional framework for action which was endorsed
by the fifty-fifth session of the Regional Committee for the
Eastern Mediterranean in 2008. The new strategy calls for
continuing action in this direction by: developing health
adaptation strategies to climate; building the institutional
capacity of the health sector in relation to extreme weather
events, and in reinforcing surveillance in the areas of infectious and respiratory diseases, food safety, and nutrition;
and establishing early warning systems on climate-sensitive
diseases.
Sustainable development and health
The relationship between health and sustainable development has three main components: improvements in health
contribute to the achievement of sustainable development
and to poverty reduction; health can be one of the principal
outcomes of investment in sustainable development and the
green economy; and health indicators provide a powerful
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means of measuring social, economic and environmental
progress towards sustainable development.
The strategy calls for: strengthening partnerships and
alliances both inside and outside the health sector to address
the emerging challenges; positioning health at the centre of
sustainable development through measuring and increasing
the health gains from development; and promoting health
impact assessment for development policies and projects.
Monitoring and evaluation
Table 5 summarizes the indicators and targets that will be
achieved during the life span of the regional strategy on
health and the environment.
Conclusions and way forward
This paper has summarized the recently endorsed regional
strategy on health and the environment in EMR, depicting
the high burden of environmental risks from communicable
and noncommunicable diseases in the Region and, at the
same time, the availability of cost-effective environmental
health interventions from prevention to mitigation to control.
The new strategy was designed to support countries
of the Region in their concerted efforts to reduce the toll
of morbidity, disability and premature mortality caused
by environmental risks. In order to do so, the ministries
of health in the Region will need to assume the roles of
stewarding broker and interlocutor in partnership with
other actors within their respective governments. It is essential that a collaborative multiagency approach is adopted,
emphasizing the leadership role of the health sector in terms
of governance and surveillance responsibilities, as well as
advocacy and motivation of other specialized environmental
health service providers. The strategic actions will be carried
out, and indicators monitored and evaluated jointly by the
WHO Secretariat (through the results-based biennial
workplans) and by countries of the Region.
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