Although the global economy has grown markedly, with global GDP increasing from $3 trillion to more than $30 trillion in the past 50 years, that growth has bought with it increasing inequalities between countries so that by the late 1990s the 20% of the world’s population in the highest income countries had 86% of the world’s GDP and the bottom fifth just 1%. Environmental effects of economic growth based largely on the exploitation of fossil fuels are becoming manifest. There has been an unrivalled build up of greenhouse gases, particularly since the 1980s and 14 of the warmest years in history have occurred since 1980. The world is now committed to substantial changes in climate over the next 100 years or so.

Many of these changes, both positive and negative, have implications for public health in Europe by affecting the underlying determinants of disease, the risk factors which lead to specific diseases or the delivery of health care. There are substantial differences in the time scale over which changes in the determinants of disease operate, some deaths are caused by events now such as getting drunk, being involved in a fight and dying and some take longer such as an individual who begins to smoke as a teenager and dies from lung cancer at aged 50. The policy decisions we take today may therefore affect health many years into the future.

There has been marked divergence in trends in life expectancy between different parts of Europe over the last 30 years( slide 3). Life expectancy at birth in EU countries has been rising steadily over this time and there has been a slower and delayed rise in countries of central and eastern Europe. In the former Soviet Union there was a pronounced fall over the early 1990’s; a temporary recovery in the late 1990s was followed by a further deterioration. The reason for these changes has been studied by a number of my colleagues at LSHTM, including Martin McKee and Dave Leon, and they have shown that these have been driven by increases in deaths due to cardiovascular disease and injuries and violence, with binge drinking playing an important role. The underlying reasons for such dramatic shifts must certainly lie in the major social changes that took place over that period.

Over the past 40 years, there has been a pronounced decline in fertility rates which are well below replacement level in a number of countries. Declines in fertility accompanied by increasing longevity have resulted in dramatic increases in old age dependency ratios, i.e. the ratio of those in work to those who have retired( slide 4 ).These are projected to increase further over the next 50 years and point to the need to maintain the health of the elderly, particularly by developing effective approaches to preventing and treating conditions such as Alzheimer’s disease for which a number of promising drugs are being evaluated.

One of the major contributors to the improvement in death rates in the EU has been striking falls in ischaemic heart disease mortality ( slide 5). This is probably due to improved access to fruit and vegetables which contain antioxidants and improved health care, including the treatment of high blood pressure. Improvements however, have been much less amongst the elderly than the middle aged .

We cannot be complacent about prospects for the future because trends in some important risk factors appear to be worsening. In particular there has been a substantial increase in the prevalence of overweight and obesity in European children (slide 6) due to an increasingly sedentary lifestyle and perhaps increasing consumption of ‘convenience foods’ . In some countries more than a quarter of children are now overweight or frankly obese (slide 7) and this is associated with increasing prevalence of impaired glucose tolerance and type 2 diabetes( slide 8) which of course is a major risk factor for ischaemic heart disease. In addition smoking, particularly amongst women, has increased in a number of countries and has been followed by an increase in death rates from lung cancer ( slide 9). The countries of Eastern Europe and the former Soviet Union have been particularly targeted by the tobacco industry (slide 10 ). Exports of cigarettes have grown by 42% between 1993 and 1996 with four companies controlling 75% of the world’s cigarette market which is worth about $400 billion annually.

Indicators of mental health have given rise to concern in a number of countries and there are wide variations in suicide rates, which are particularly high in Hungry and Croatia (slide 11). Although effective antidepressants are widely available and there is now good evidence for the effectiveness of brief psychotherapy based on cognitive behavioural principles, there is a need for better detection of depression and delivery of effective treatments, particularly through primary care.

There are also wide discrepancies between countries in death rates from injuries in childhood, many of them related to road traffic accidents ( slide 12). Parental concern about road traffic accidents involving children may also be a factor in increased obesity, as children become less likely to walk or cycle to school.

The prevalence of HIV is increasing in many parts of the world, including in a range of European countries (slide 13). Russia in particular has experienced very large increases over the last 5 years and newly diagnosed cases run from less than 10 per million population in some central and eastern European countries to over 400 in Russia ( slide 14). In Russia a substantial proportion of cases are related to intravenous drug use.

A rise in other sexually transmitted diseases such as syphilis has occurred in some countries. An increase in death rates due to cervical cancer in countries such as Romania (slide 15) could be the result of a number of factors including the rise in sexually transmitted infections, the failure of some screening programmes to reach those at risk and the poor quality of some smear tests. There is growing awareness of the of the immense human tragedy caused by the trafficking of women and girls for sexual exploitation, with estimates as high as 500,000 in Western Europe alone.

At the same time as we have seen a resurgence in some infections established treatments are losing their effectiveness. Antibiotic resistance is a growing problem in many countries and appears to be related to overuse of antibiotics (slide 16). A relationship is apparent between penicillin sales and the prevalence of resistance to penicillin in a range of European countries. An increasing problem of multi drug resistance is manifesting itself in the case of TB. Overall annual notifications of TB have increased in recent years in Eastern Europe (slide 17) and the proportion of multi drug resistant TB is increasing( slide 18). It has reached high levels in a number of countries particularly Latvia, Estonia and Lithuania. This trend has been driven by poor adherence to appropriate treatment regimes and is being addressed by the implementation in a growing range of countries of the ‘DOTS plus’ approach adopted by WHO which promotes the use of appropriate diagnosis and treatment regimes. Richard Coker and Martin McKee at LSHTM are working to improve the management of TB, including collaboration with Russian colleagues to address the problem of inadequate treatment in prisons. ( slide 19).

The emergence and resurgence of communicable disease threats poses challenges for surveillance in Europe (slide 20). National surveillance systems contrast with EU free trade which encourages movement of people and goods. Some outbreaks may only be detected by pooling national surveillance data in different countries, such as a Legionnaires disease cluster associated with staying in a single hotel. Outbreaks of disease originating from other parts of the world ,such as a virulent strain of influenza, can only be dealt with effectively by concerted action.

The changing world climate due to the accumulation of greenhouse gases will have impacts in Europe. The world is now committed to several degrees warming over the next century ( slide 21) which is likely to result in a range of health impacts , most of them adverse. Increased heat related deaths in summer months are likely ,particularly in urban centres, although in Europe these may be counterbalanced by decreased cold related deaths in winter months( slide 22). However if the ocean circulation that transports warm water to the Atlantic weakens, Europe could become colder despite an overall increase in global temperature .The likelihood of this happening is thought to be very low but will increase with the rate, magnitude and duration of climate change.

Increased flooding is predicted due to increases in heavy precipitation. Recent floods affecting central Europe, including Germany and the Czech Republic, demonstrated not only the profound economic impacts of floods ( 15 billion euros in Germany alone) but also the disruption they can cause to society. In addition to immediate deaths( 100 in the recent floods) and injuries, floods can cause substantial and in some cases long lasting effects on mental health due to increased rates of depression and suicide.
Climate change may also affect distribution of vector borne diseases, such as tick borne encephalitis and leishmaniasis. The effects of climate change in other parts of the world where populations are even more vulnerable may have implications for Europe by, for example increasing the number of displaced people. The failure to make progress on this issue at the recent World Summit has further underlined the need to improve our capacity to adapt to changes in climate as well as redoubling efforts to secure substantial cuts in fossil fuel use.

Time does not permit a discussion of the full range of responses to these threats. Colleagues in my own institution, LSHTM, are actively researching on the majority of the challenges that I have outlined. For example they are working to improve links between laboratory and public health sciences in fields such as pathogen genomics which will enable us to detect changes in the virulence of organisms, and new vaccine and drug targets( slide 23). We are also developing and evaluating effective public health interventions to change behaviours, for example to reduce HIV risk, and to reduce accidents and injuries. We are researching the complex relationships between climate and human health and forging closer links between public health and primary care. We are strongly committed to post graduate teaching and training for public health both through our masters degree and doctoral programmes based in London and increasingly through our distance learning masters programme which now involves around 800 students all over the world. It is a particular pleasure for me to announce our intention to work closely with our colleagues here at the Andrija Stampar School of Public Health to develop a masters course based on our distance learning materials.

But public health is too important to be left just to us public health professionals. Many of the determinants of health can be influenced by public policies across a range of sectors including finance, education, social welfare and pensions, housing, transport, energy, environment and agriculture. We need to engage policy makers more effectively in considering the implications of their decisions on the health of the populations they serve. Health impact assessment of policies should be embedded in national and local government. The effectiveness of public policies is often judged mainly by the degree to which they promote economic growth but public health indicators can, I submit, provide a valuable measure of performance.

I would like to thank colleagues at LSHTM who have contributed to this presentation, particularly Professor Martin McKee