Inequalities, Inequities, Environmental Justice in Waste Management and Health PDF

European Journal of Public Health, Vol. 20, No. 1, 21–26 ß The Author 2010. Published by Oxford University Press on behalf of the European Public Health Association. All rights reserved. doi:10.1093/eurpub/ckp216 Advance Access published on 8 Jan...

European Journal of Public Health, Vol. 20, No. 1, 21–26 ß The Author 2010. Published by Oxford University Press on behalf of the European Public Health Association. All rights reserved. doi:10.1093/eurpub/ckp216 Advance Access published on 8 January 2010................................................................................................ Inequalities, inequities, environmental justice in waste management and health Marco Martuzzi1, Francesco Mitis1, Francesco Forastiere2 Background: The scientific evidence on the health effects of waste-related exposure is not conclusive. Differential exposure to waste by socio-economic status (SES) is often documented, but the interplay between environmental and social factors, crucial for policy making, is not well known. This review aims at investigating the role of health inequalities and inequities in waste management. Methods: Grey and peer-reviewed literature, published after 1983, was reviewed from Europe and the USA. Results: Available data provide consistent indications that waste facilities are often disproportionally more located in areas with more deprived residents, or from ethnical minorities. This applies to waste incinerators, landfills, hazardous waste sites, legal and illegal. In studies considering health effects (mainly from Europe), risks are estimated with standardization for SES. Such standardization almost always decreases risk estimates for several cancers and reproductive outcomes. However, effect modification is not investigated in these studies. Conclusions: The patterns of association between waste-related environmental pressures and SES suggest that some of the observed inequalities in exposure and health represent a case of environmental injustice as they are the result of social processes and may be prevented, at least partly. Disentangling the possible health effects remains difficult, due to limitations in the methodology. It seems important to investigate if disadvant- aged people are more vulnerable, i.e. risks differ in different social groups living in the same area. Notwithstanding these open questions, public health officers and decision makers should identify waste management policies to minimize their potential health impacts and their unequal distribution. Keywords: adverse effects, environmental exposure, hazardous waste, health effects, social class, socio- economic factors................................................................................................ Introduction example to age or individual predisposition) can be regarded as inequities (i.e. avoidable differences, for example in access Waste and health: scientific evidence and to healthcare service, preventing individuals from attaining knowledge gaps their full health potential, and carrying an ethical negative judgement) and as such result in environmental injustice. Given the growing production of waste, policy-makers are The present contribution is dedicated to the role of socio- increasingly confronted with the necessity of developing economic differences and environmental justice on the more capacity to safely dispose of waste. Despite the lack of potential health burden due to exposure to hazardous waste univocal evidence on the health implications of waste-related facilities. environmental exposures, there are concerns over the health effects of different waste management options, including land filling, incineration, disposal of healthcare and other hazardous Role of social health determinants waste.1 Social determinants of health have a strong influence on Further insights on health effects of landfills and incinera- virtually all health endpoints considered in studies designed tors are needed; it is important to investigate these possible to assess the role of waste–related exposure. As in many effects in conjunction with other environmental hazards, as other fields in environmental health, this realization has concurrent exposures can result in synergistic health effects. resulted in the adoption of methodology to formally take In particular, it is of interest to consider how possible health into account these effects in epidemiological studies. effects of waste may take place in combination with other Typically, socio-economic factors have a strong potential for powerful health determinants depending on lifestyle and the acting as confounders of the parameter of interest, i.e. the social environment. It is urgent to clarify how population association between health and waste exposure. This is distribution of waste-related exposures (i.e. how uneven are because exposed subjects often have socio-economic char- such exposures among different subgroups) can inform the acteristics that can differ from those of unexposed subjects, policy response, affect its effectiveness and acceptance, and and thus create differences in risk that could be erroneously how these aspects can be taken into account more system- attributed to waste. This is why effects of socio-economic atically in policy-making. In particular, it is of great interest factors are often regarded, in epidemiological studies, as to clarify what proportion of health inequalities (i.e. general nuisance factors, and standardization techniques are applied differences in health status and in exposure levels due for to remove their contribution and assess the waste–health association, net of the influence of socio-economic factors. 1 This routine standardization reflects the strong expectation World Health Organization (WHO) Regional Office for Europe, that socio-economic factors are associated with environmental Rome Office, Rome, Italy 2 exposures—a prerequisite for a confounding effect. The Local Health Authority Roma E, Rome, Italy systematic adoption of this practice relies on an important Correspondence: Marco Martuzzi, World Health Organization (WHO) Regional Office for Europe, Rome Office, Via Francesco assumption, and suggests a certain attitude: the assumption Crispi, 10-I-00187, Rome 00198, Italy, tel: +39-06-4877520, is hazard proportionality, i.e. health risks from socio- fax: +39-06-4877599, e-mail: [email protected] economic conditions act as multipliers of an independent 22 European Journal of Public Health risk due to environmental factors. In other words, through dumps than other variables, such as household income, standardization for socio-economic factors the environmental the value of homes and the estimated amount of hazardous risk is assumed constant across different social strata, and the waste generated by local industry. possibility of modification of effect (for example, different risks Brown17 reviewed (i) exposure to toxic hazards, includ- for different socio-economic groups) is seldom investigated. ing the presence of hazardous waste sites and facilities The attitude is the one of considering the multiple effects as (ii) regulations, ameliorations and cleanups, including record independent of each other and attaching less importance to of decisions and cleanups at National Priority List (NPL) sites the contextual ones. Admittedly, full, holistic consideration of and (iii) regulatory actions, as measured by assessed fines for the mutual action of different risks is very challenging and is environmental pollution; he concluded that ‘the overwhelming often not feasible; however, a fuller understanding of how bulk of evidence supports the ‘‘environmental justice’’ belief environmental risk factors operate in the reality of the social that environmental hazards are inequitably distributed by environment would be very informative especially for class, and especially race’. These results were confirmed by designing effective policy responses. the most recent study,18 and the underlying social processes In this paper we examine the evidence and the implications were analysed in different settings.15,19,20 of the confounding effect of socio-economic factors. First of all Compared to US studies, European data are based on a then, we address the question of how strong is the evidence different approach to measuring socio-economic status that more deprived communities are more exposed to waste- (SES), based on composite indices built combining infor- related contaminants; later, we examine how these gradients, mation on several domains, such as social class, education, where observed, can influence the risks for several health unemployment, housing, family structure, rather than endpoints, considering how risks differ before and after variables such as income or ethnicity. adjustment for socio-economic factors. Finally, we discuss The association between social characteristics and resid- the implications of these inequalities. ence in the vicinity of waste sites has been repeatedly documented in England and Wales. Several studies analysed the correlation between income and deprivation with local- Methods ization of solid waste and other polluting facilities, finding Grey and peer-reviewed literature, published after 1983, when that facilities were disproportionally located in the more an influential paper appeared,2 was reviewed from Europe and deprived areas.21–23 The correlation was not always observed the USA. for landfills at the subregional level.24 Keywords or references in the titles to ‘waste’, ‘health At the national level, a study by Elliott et al.25 showed that effects’, ‘socio-economic factors’, ‘inequities’, ‘environmental ‘the area within two km of the 9565 landfill sites tended to be justice’, ‘congenital anomalies’ and ‘mortality’ were used to more deprived than the reference area: 34% (versus 23%) of search the Medline database. All European studies were the population were in the most deprived tertile of Carstairs selected. With regard to US studies, given the large amount score (36% for special waste sites)’. of literature dealing with social differences on the residence A national study on environmental inequalities in France on near waste facilities, only the most s studies were chosen the distribution of environmental burden tested the hypothesis and commented. The grey literature was searched with the that poor and immigrant communities are disproportionately same criteria using Google Scholar and looking at the key exposed to environmental risks. Eight types of hazardous sites references listed in the peer-reviewed articles to identify (industrial and nuclear sites, incinerators, waste management nongovernmental organization (NGO) reports and studies facilities) and the socio-economic characteristics of popula- published by other agencies. A total of 47 studies were tions were associated at the commune, or town, level for all included in the review. 36 600 French towns. The results of the spatial regression analyses showed that towns with high proportions of immigrants hosted more hazardous sites, even controlling for Results population size, income, degree of industrialization of the town and region.26 Residence near waste facilities: unequal In the European Union project Integrated Assessment of and inequitable Health Risks of Environmental Stressors in Europe The characteristics and main findings of the identified studies (INTARESE), an integrated approach for the health impact are summarized in Supplementary Table 1. assessment of landfills and incinerators on the population The first studies on environmental justice, contaminated living in the surroundings has been applied in Italy, UK sites and waste were carried out in the USA and were and Slovakia, for a total 905 municipal urban solid waste prompted by the concerns of civil activists on the dispro- landfills and 53 waste incinerators.27 A direct relationship portionate location of landfills in predominantly black was found between social class and residence near waste communities.3 The correlation between race, income and facilities in Italy and UK, and an inverse relationship was residence influenced several outcomes such as a higher found in Slovakia (Table 1). For incinerators, this may be likelihood of being exposed to environmental hazards, the due to the location of the two facilities in urban areas, where disproportionate impacts of environmental processes and most affluent Slovakian people live. policies, the targeting and siting of noxious facilities in more The results of European Collaborative Study of Residence deprived communities and inequalities in the delivery of near Hazardous Waste Landfill Sites and Risk of Congenital environmental services such as rubbish removal.4–6 Malformations (EUROHAZCON),28 a multisite study that Other studies found skewed distributions around waste considered 21 landfills in several countries, suggested sites, with less affluent population subgroups, and with more ‘no overall evidence that socio-economically more deprived black people, living in the surroundings of the facilities.2,7–9 communities live near to landfill sites’. In a US national assessment10,11 (later updated12), a correlation An inverse relationship was also found in a study of a Welsh was found between proportion of black residents and landfill, where most affluent people were found to be living the presence of hazardous waste sites in the surroundings. closer the site.29 Although these results were criticized,13–16 ethnicity was Cancer mortality and congenital anomalies of populations considered to be a stronger predictor of the presence of toxic living in 196 municipalities of two provinces of Campania  Environmental justice, waste and health 23 Table 1 Characteristics of residents living close to waste facilitiesa in Italyb, Slovakia and England, by quintiles of deprivation index, 2001 Landfills Incinerators Italy Slovakia England and Wales Italy Slovakia England and Wales Number of sites 619 165 232 40 2 11 Population within 2 km 1350 852 328 869 1425 350 1060 569 16 409 1203 208 Most affluent population (I group, %) 13.3 24.2 2.5 12.6 55.6 30. II group 15.0 24.7 17.9 15.1 2.4 6.3 III group 22.4 22.6 18.7 21.0 9.8 12.5 IV group 23.0 16.4 19.1 24.2 29.6 22.8 Most deprived population (V group, %) 26.1 12.1 20.1 24.9 2.5 55.4 Missing information (%) 0.0 0.0 21.7 2.2 0.2 0.0 Source: adapted from Forastiere et al.27 a: 2 km from municipal urban solid waste landfills; 3 km from waste incinerators b: 118 landfills were geocoded, for population of 257 513. Socio-economic data were then extrapolated to 619 landfills Region, southern Italy, were recently investigated.30 The study adjusting for these factors, risks decreased for all the area was characterized by more than 20 years of waste anomalies under study, more markedly in areas with the mismanagement (with the involvement of organized crime), highest special waste sites density.25 including uncontrolled waste disposal, release of toxic In a subsequent study43 a decreasing risk of Down’s substances and illegal waste burning. A positive correlation syndrome with increasing levels of socio-economic deprivation (r = 0.30) was found at municipality level between a waste was observed; however, adjustment for SES resulted in a exposure indicator (built using 227 waste facilities sites–138 marginal correction of the estimates of the risks from of which illegal) and a deprivation index.30 landfills, perhaps not surprising because of the strong effect Interest in environmental justice and in unequal distribution of maternal age. of environmental hazards and benefits has recently grown in In another UK study on cancer and residence near landfill countries of central and eastern Europe. It has been sites,44 adjustment for SES decreased the risk estimate for documented that hazardous sites and illegal waste disposal bladder cancer, which however remained significantly in activities are disproportionally located in the working-class excess. The same was observed for hazardous sites, but the areas, as in Hungary with illegal asbestos disposal,31 and in adjusted risk for bladder cancer lost statistical significance. communities of ethnic or national minorities, predominantly In the EUROHAZCON multi-site study a positive the Roma populations,32–34 whose camps are often settled on association was reported in the UK between SES and non- (or near) contaminated sites. The Hungarian National Public chromosomal congenital anomalies close to landfills.28 The Health and Medical Officers’ Service reported, for example, risk in the most deprived group was 40% higher than in the that 15% of the 767 Roma colonies identified in Hungary, most affluent quintile; an impact measure was also estimated: for a total of three million persons, are within 1 km of illegal if the rates observed in the most affluent group prevailed in the waste disposal sites, and 11% within one km of animal carcass whole exposed population, the 18% fewer anomalies would disposal sites.35 have occurred.45 This pattern was not observed in other In addition, minority groups in European countries are European sites. more at risk of environmentally based discrimination In a study carried out in Campania a positive association because they are more likely to be object of discrimination, was observed between mortality for various cancer causes and and be segregated in enclaves or in deprived zones along the both illegal waste exposure and socio-economic factors. For borders, or in refugee camps.33,36,37 both sexes, mortality risk estimates unadjusted by socio- Finally, besides differential levels of exposure to waste- economic deprivation were much higher than adjusted ones, related contaminants by socio-economic levels at local or as shown in Table 2. Risk estimates were markedly corrected national level, inequalities in exposure might take place at across the five levels of waste exposure, and so were estimates the international level, through the transfer of related of linear trends. The only exception was stomach cancer in hazards from one country to another.38,39 In fact, illegal men.46 shipment and disposal of hazardous waste is of growing In a study in the New York state near PCB-contaminated relevance in some countries of central and eastern Europe.40,41 (i) superfund sites, (ii) NPL sites and (iii) the six areas of concern,47 the risk of giving birth to a low-birth-weight and Exposure to waste and socio-economic factors: to a very low-birth-weight baby was investigated. Positive compounded effects associations were observed between having a low-birth- Many of the studies above, especially from Europe, document weight baby and (i) low levels of income and (ii) mother’s a pattern where deprived people are overrepresented in the educational level less than (or equal to) high school while vicinity of waste treatment facilities. In some of these studies, only a low-income level was associated to having a very in addition, it is observed that health effects—notably low-birth-weight baby. mortality, congenital anomalies, low birth weight—are Another US study48 considered only ethnic minorities associated with socio-economic factors. (Black/African American, Hispanic/Latino, American Indian/ Several studies were performed in UK on congenital Alaska Native and Asian/Pacific Islander) and found a positive anomalies,25,42 Down syndrome43 and cancer44 in population association between a range of anomalies and residence in the living near landfills. In a recent study on congenital anomalies census tracts near the NPL hazardous waste sites. The largest and landfill density, risks were standardized by SES, presence association was found between potential exposure and of a congenital anomalies registry and maternal age. On neural tube defects [odds ratio (OR) = 1.54, 95% confidence 24 European Journal of Public Health Table 2 Waste exposure, SES and mortality outcomes in Campania regiona Mortality excess (%) risks by waste exposure groupb I II III IV V Trend Unadj Adjc Unadj Adj Unadj Adj Unadj Adj Unadj Adj Cause of death—men All causes — 9.2 5.4 6.9 7.9 7.1 3.9 13.6 9.2 2.2 1.7 All cancers — 9.3 4.2 3.2 5.6 9.3 4.9 11.0 4.1 2.2 1.5 Lung cancer — 11.4 5.5 4.2 6.4 11.1 6.1 14.0 6.7 2.7 1.9 Liver cancer — 0.1 9.2 12.7 20.6 7.0 0.7 35.5 19.3 5.6 4.3 Stomach cancer — 1.5 3.0 0.1 2.8 17.0 19.4 16.2 15.7 5.0 5.2 Bladder cancer — 17.3 11.7 11.0 6.4 10.8 7.1 4.6 4.1 0.8 0.7 Kidney cancer — 4.4 2.8 4.3 0.6 8.5 14.9 7.6 16.7 3.0 4.0 Soft tissues sarcoma — 10.6 9.8 7.2 20.4 23.6 31.0 18.7 25.0 3.1 3.9 Non Hodgkin lymphoma — 24.2 9.4 29.8 25.4 18.7 6.8 2.8 3.7 2.3 1.3 Other cancers — 9.1 4.7 2.4 4.3 7.6 3.3 6.2 0.3 1.4 0.7 Cause of death—women All causes — 3.1 1.7 7.2 8.1 5.6 4.8 14.4 12.4 2.6 2.4 All cancers — 9.8 5.1 2.3 2.4 6.7 3.6 10.0 6.6 1.6 1.0 Lung cancer — 63.8 45.4 10.2 14.4 14.1 5.6 22.7 9.4 0.2 2.3 Liver cancer — 3.5 9.3 5.0 9.1 13.6 9.6 39.5 29.1 7.3 6.6 Stomach cancer — 8.1 8.3 2.3 6.4 1.0 2.2 10.7 16.7 2.1 2.6 Bladder cancer — 17.9 7.7 6.5 12.7 3.2 2.8 17.3 16.7 2.8 3.3 Kidney cancer — 19.2 6.9 2.4 11.2 8.7 3.4 36.2 19.1 3.8 1.7 Soft tissues sarcoma — 4.3 7.7 76.0 84.1 35.2 33.6 4.2 0.3 7.8 8.3 Non Hodgkin lymphoma — 9.8 10.1 3.3 3.5 15.9 19.7 2.1 0.2 1.8 1.6 Other cancers — 7.4 3.5 1.3 1 5.2 2.3 6.3 3.7 1.1 0.7 Source: Adapted from Martuzzi et al.30 a: In bold, statistically significant risks are reported (95% CI) b: I group is used as reference, i.e. no waste-related exposure; V group has highest exposure c: Mortality excess risks (%) = (relative risk 1)  100. Risks adjusted by SES interval (CI) = 0.93–2.55]. The strongest association between birth defects and potential exposure was among American The available information on the health effects of waste Indians/Alaska Natives (OR = 1.19, 95% CI = 0.62–2.27). This facilities by social groups, needed to address these questions, study design, however, does not allow a comparison with the is limited. First, not all the studies carried out to evaluate the effects in the majority population. potential associations between exposure to waste facilities and health have considered SES; in some studies, socio-economic- Discussion adjusted risks are estimated but unadjusted risks are not published, or are indistinguishable from those due to other Waste and health: same risk for everyone? factors (for example, maternal age or the presence of a The evidence summarized above indicates that there is a dedicated registry in studies of congenital anomalies). tendency in poorer, less educated, disadvantaged people or Secondly, and crucially, in no cases are interaction effects ethnical minorities to live closer to waste treatment facilities between socio-economic factors and waste exposure tested of any kind and, in addition, that when adverse health and reported. Some studies are designed with selected popu- effects due to such proximity are detected, these are often lations either highly exposed47 or from socially disadvant- compounded (usually multiplicatively) with the adverse aged,48 making the assessment of the interaction impossible. effects of social disadvantage. This pattern may occur for For waste and health as well as for many other cases in other localized source of environmental pollutants, but is not environment and health, these issues are central; together systematically documented. On the whole, the evidence with better quality data on waste-related exposures, suggests marked inequalities in the health pressures and recognized as a prerequisite for more informative studies,1 impacts due to the combination of environmental and social more detailed information on exposure and health by the factors. Some of these inequalities are due to socially driven socio-economic group would not only shed light on the processes, for example residential segregation or differential nature of the interrelationship between the social and the access to health-promoting resources, amenable to mitigation. physical environment but would also allow the identification Some questions arise from these observations. of more effective strategies to prevent or reduce the impacts. There are, however, substantial difficulties in estimating  Are disadvantaged people, besides being disproportionally the joint effects of different risk factors, for example, exposed to waste-related environmental risk, also more low power to estimate interactive effects, given the high vulnerable to its impacts? collinearity between environmental exposures and depriva-  Do risks differ in different social groups living in the same exposed place and, if so, to what extent? tion. This is one facet of environmental justice: different  In other words, is there an interactive, synergistic relation- risk factors, such as environmental contamination, social ship between the adverse health effects of waste exposure disadvantage, unhealthy lifestyles, are often observed to and of the disadvantaged social environment, or conversely insist on the same subgroups. This makes the assessment does the proportionality assumption hold? of the interplay between these different factors difficult  How preventable are the observed inequalities? and represents an important reason to consider inequalities  Environmental justice, waste and health 25 (in exposure and in health outcomes) as inequities. Other Supplementary data relevant considerations in terms of equity include the following. Supplementary data are available at EURPUB online.  While a certain degree of inequalities are inevitable, at least a part (arguably a substantial one) of the observed Acknowledgements inequalities is preventable. Exposure inequalities can and must be reduced by appropriate measures of mitigation The authors would like to acknowledge Lubica Palkovicova and abatement of emissions from potential sources. This and Kees De Hoogh for providing data on Slovakia and UK. includes not only established noxious agents (for example, They are grateful to Pietro Comba for his useful suggestions. particulate matters, persistent organic pollutants, heavy metals) but also emissions interfering with residents’ quality of life (for example, odours, noise). Inequalities Funding can be further countered by primary prevention and Partly funded by INTARESE, an Integrated Project of the EU health promotion initiatives undertaken in conjunction. 6th Framework Programme.  It is possible that people who bear the most part of the adverse impacts from waste disposal activities (in terms of Conflicts of interest: None declared. health and well-being) produce less waste. This might occur, for example, when residential exposures are disproportionately distributed towards population strata Key points with lower income, lower purchasing power and lower rates of consumption of material goods. There are  The expectation that waste-related environmental examples, in other domains, where this unfair, negative exposure is stronger in disadvantaged population correlation between benefits and negative impacts is subgroups is confirmed by most studies available in obvious (for instance, greenhouse gas emission at global Europe and the USA. level) and similar mechanisms may take place at more  The effects of socio-economic health determinants are local level too. often removed, through standardization, in epidemio- logical studies; the possible occurrence of modification Currently, both of these dimensions of environmental of effect would be of great interest, but is not justice are, by and large, speculative. Data and evidence to documented. assess the extent of these inequities would be highly  Despite the limited understanding of the interplay informative. between waste-related exposures and social health determinants, observed patterns raises a question of environmental justice, which require adequate policy responses. Conclusions Numerous studies in Europe and in the USA have documented that disadvantaged communities often suffer disproportion- ately from the impact of waste facilities. Several questions are unresolved that should be addressed with the collection References of targeted data and research. Uncertainties include the 1 World Health Organization Regional Office for Europe. Population health presence and magnitude of environmental different waste- and waste management: scientific data and available options. 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