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Keywords:public health concerns, world health organization, margaret phillips, central and eastern europe, constitutional functions, postindustrial society, information and guidance, former ussr, regional publications, health strategies, specialized agency, environmen, principal objective, health matters, transport environment, s books, international distribution, international health, human health, regional office

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Many countries in Europe are concerned with the nu merous effects of transport policies on health, and gov ernments want to ensure that these are addressed in the most effective and efficient way. Very good evidence shows that some transport policies bring benefits to health and the environment, while others are harm ful. The challenge is to select the policies with the most overall benefits to society. The urgency of the need to respond to this challenge is vividly demonstrated by the massive increases in motor vehicle traffic and by the strong public reaction against the noise, air pollutants and congestion........

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#font 2827 "AGaramond BoldItalic 286 0" 24 Note: not #font 2483 "BaskervilleExpBQ RegularOsF 285 0" K UNZLI , N. ET AL . #font 2278 "BaskervilleExpBQ Regular 284 0" Berglund, B. Lindvall, T., ed. Berglund, B. et al. WHO European Centre for Environment and Health. Stanners, D. Bordeau, P., ed. Sandberg, U., ed. Bronzaft, A.L. Mannan, M.S. et al. Laurell, H. Hillman, M. et al. Finch, D.G. et al. Bly, P.H. Pasanen, E. Richter, E.D. Borkenstein, R.F. et al. Hurst, P.M. et al. Carsten, O. European Commission. Carlsson, G. Pope, C.A., III et al. Dockery, D.W. et al. Morris, R.D. et al. Health Effects Institute. Van Wijnen, J.H. Van der Zee, S.C. Brunekreef, B. Ciccone, G. et al. Needleman, H.L. Gatsonis, C. Dietrich, K.N. et al. Damm, D. et al. White, R.F. et al. Goldberg, L. Gara, M.A. Green, M.M. et al. De Horne, L.D.J. Stallard, P. et al. Novaco, R.W. et al. Mayer, R.E. Treat, J.R. Marsh, P. Collett, P. Joint, M. Whitlock, F.A. Cassidy, T. Appleyard, D. Lintell, M. Greenwood, D.C. et al. Httenmoser, M. Stephens, T. Craig, C.L. Stephens, T. US Department of Health and Human Services. Morris, J.N. Hardman, A.E. Oja, P. et al. Vuori, I. Oja, P. British Medical Association. Murphy, M.H. Hardman, A.E. Pate, R.R. et al. Hydn, C. World Health Organization World Bank. Vuori, I.M. et al. Maddison, D. et al. Croxford, B. et al. Brunekreef, B. et al. Duhme, H. et al. Oosterlee, A. et al. Edwards, J. et al. Weiland, S. et al. Lercher, P. et al. Kendrick, D. Joly, M. et al. Stevenson, M. et al. Mueller, B. et al. DiGuiseppi, C. et al. Van Wijnen, J. et al. Institute for European Environmental Policy Environmental Transport Association. Poloniecki, J. et al. Morris, R. et al. Pope, C.A. Dockery, D.W. Garcia, A. et al. Griffiths, I. Raw, G. Kolbenstvedt, M. Ward, H. et al. Vagero, D. Ostberg, V. Davies, D. et al. Dejoy, D. Kuhl, D. Cooper, C. Krause, N. Federation of European Pedestrian Associations. Hillman, M. Department of Health Committee on the Medical Effects of Air Pollutants. Townsend, P. Davidson, N., ed. Benzeval, M. et al., ed. INFRAS AG I NSTITUT FR W IRTSCHAFTSPOLITIK UND W IRTSCHAFTSFORSCHUNG IWW U NIVERSITT K ARLSRUHE S OMMER , H. ET AL . #font 1252 "Symbol 282 0" #font 829 "Helvetica 280 0" Dwellings IndoorsSpeech intelligibility and16 hours35 moderate annoyance, daytime and evening Inside bedroomsSleep disturbance night 8 hours3045 time Outside bedroomsSleep disturbance, window8 hours4560 open outdoor values Schools and preschools Classrooms indoorsDisturbance of speechDuring class35 intelligibility, information extraction and message communication Preschool rooms indoorsSleep disturbanceSleeping time3045 Playground outdoorsAnnoyance external source During play55 Hospitals Wards Rooms indoorsSleep disturbance night time 8 hours3040 Sleep disturbance daytime16 hours30 and evenings Treatment rooms indoorsInterference with rest andAs low as recoverypossible Other Outdoor living areaSerious annoyance,16 hours55 daytime and evening Moderate annoyance,16 hours50 daytime and evening Industrial, commercialHearing impairment24 hours70110 shopping and traffic areas, indoors and outdoors Ceremonies, festivals andHearing impairment from4 hours100110 entertainment eventsattending 5 times year Public addresses,Hearing impairment1 hour85110 indoors and outdoors Music throughHearing impairment free 1 hour85110 headphones earphonesfield value Impulse sounds fromHearing impairment adults 120 a toys, fireworks and firearmsHearing impairment children 140 a Outdoors in parklandDisruption of tranquillityExisting quiet outdoor and conservation areasareas should be preserved and the ratio of intruding noise to natural background sound should be kept low. a Peak sound pressure not LAmax, fast , measured 100 mm from the ear. AlcoholControl of blood alcoholPrevention of 540 of deaths if concentration while drivingblood alcohol concentrations were never greater than 0.5 g litre Enforcement strategies to reduce20 reduction in deaths from alcohol related accidentsthe introduction of highly visible random breath testing evidence from New South Wales, Australia SpeedAverage speed reduction by 5 km25 reduction in deaths estimates per hourfor EU countries Widespread use of speed cameras50 reduction in relevant accidents Use of local and variable speed limits30 reduction in accidents resulting in severe injuries evidence from Germany Speed reduction measures inAccident reductions of 1580 residential areas experience in EU countries Use of safety devicesIncreased wearing of seat belts15 reduction in deaths of car occupants estimated if best compliance levels were matched across the EU 95 use Increasing use of motorcycle and50 reduction in injuries head cycle crash helmetsinjuries Day running lights5 reduction in deaths Vehicle designAll cars constructed to the best level15 reduction in deaths of passive safety in their size category estimates for EU Introduction of pedestrian friendly car designsA further 7 reduction in deaths Light traffic 200 vehicles at peak hour 3.06.3 Moderate traffic 550 vehicles at peak hour 1.34.1 Heavy traffic 1900 vehicles at peak hour 0.93.1 Accidents155.64062.3 Air pollution134.33502.0 Congestion128.43351.9 Climate change121.83181.8 Upstream processes56.51470.8 Noise36.5950.5 Landscape16420.2 Urban effects8.9230.1 Total65817169.7 #font 826 "Helvetica Black 281 0" EnvironmentCritical health effect s TimeLAeqLAmax, base dB fast dB Risk factorMeasureEstimated effect Traffic levelsContacts living on the same street FriendsAcquaintances EffectCost TotalPer personShare of gross billion euros euros domestic product #font 632 "Frutiger Light 276 0" site on transport data for the Member States . Brig Zrich, rztinnen und rzte fr Umweltschutz, 1995. Berglund et al. . Health for all database, WHO Regional Office for Europe, 1999. and European Commission . adapted from Appleyard Lintell . Sustrans. Bristol, Sustrans, 1996 Information sheet FF10 . . INFRAS AG and Institut fr Wirtschaftspolitik und Wirtschaftsforschung IWW Universitt Karlsruhe . United Nations Economic Commission for Europe UN ECE #font 629 "Helvetica Light 275 0" T #font 474 "Frutiger LightItalic 274 0" Europes environment: the second assessment 1 . ransport in figures: 2 Lrm und Gesundheit. 6 A strategic road safety plan for the European Union 17 29 Overview of the environment and health in Europe in the 1990s 40 . 62 Safety on the streets for children. Walking and cycling in the city 79 114 #font 286 "AGaramond Italic 273 0" ment, regulation and economic analysis, and identi fies the areas where action is most needed. Discussions of the environment and health effects of transport need to be communicated in a way that is relevant for policy makers and easily understood by non scientists. That is the aim of this book, which summa rizes the results of extensive reviews of the issues prepared by groups of prominent international experts. It is also planned to release the reviews themselves, to give a more detailed account of the scientific evidence. The WHO Regional Office for Europe is grateful for the support of the Austrian Ministry of Agriculture, Forestry, Environment and Water Management, which brought the expert groups together, facilitated the pro duction of the resulting publications and led the nego tiations that resulted in the adoption of the Charter. The Regional Office is also thankful for the support and creative collaboration provided by the United Nations Environment Programme and the European Environment Agency. This book makes an important contribution to stronger collaboration between health, transport and environ ment professionals and administrations. This should ultimately lead to the achievement of transport systems that are sustainable for health and the environment. Many countries in Europe are concerned with the nu merous effects of transport policies on health, and gov ernments want to ensure that these are addressed in the most effective and efficient way. Very good evidence shows that some transport policies bring benefits to health and the environment, while others are harm ful. The challenge is to select the policies with the most overall benefits to society. The urgency of the need to respond to this challenge is vividly demonstrated by the massive increases in motor vehicle traffic and by the strong public reaction against the noise, air pollutants and congestion that make cities unliveable. The countries of the WHO European Region came to gether to prepare a Charter on Transport, Environment and Health that identifies their concerns, defines health targets for transport policies and provides a plan of ac tion to achieve them. In the negotiations, ministries of transport, of health and of the environment worked together for the first time to find a common language and to agree on collaborative actions. The Charter was adopted at the Third Ministerial Conference on Envi ronment and Health in June 1999. This book brings together the scientific evidence on the main effects of transport on human health and the en vironment. It sets the conceptual framework for future analyses of the health burden and health gains from transport policies. It outlines how these health concerns have been reflected in policy tools such as impact assess No sector is developing in such an unsustainable way as the transport sector. From 1970 to 1995, motor traf fic in the European Union doubled, while the share of walking, cycling and public transport fell drastically. This trend is predicted to continue and gain further strengthen if business continues as usual. WHO deals intensively with the negative consequences of transport on human health and environment and proposes measures for improvement. In the Charter on Transport, Environment and Health, WHO Member States have formulated a set of strategies to reduce en vironmental pollution and health risks. For the first time transport, environment and health have been dealt with in an integrated way. Austria has gladly followed the invitation of WHO and actively supported this new policy approach. The plan of action as a key element of the Charter is therefore a major milestone on the road towards making transport in Europe sustainable for environment and health. A well founded basis for this approach was provided by the scientific substantiation documents, elaborated by expert teams for WHO. They were developed with the support of Austria and are now summarized in this book, which underlines the need to support and extend cooperation on transport, environment and health policies on the national and European levels. 1 2,3 4 5 6 5 7 6,8 9,10 11 12,13 13 13 2 14 12,14 15 12,14 15,16 16 14,16 16 17 18 19 12,14 20 15 2123 24 25 26,27 28 17,29 31 32 29 31 33 34 35 36,37 38 39 40 41 1 42 40 43 44 45 45 46 47 48 49 48 50,51 52 53 54 55 56 57 58 59 60 61 62 62 62 63 20 63 65 64 65 66 67,68 67 69 70 71 72 73 2 15 74 16 75 76 77 78 16 79 79 80 15 81 8284 85,86 87 15 88 15 89,90 91,92 93 94,95 96,97 98 99 100 101 15 102 103 104 105 15 17 106 107 108 109 110 110 12 111 112,113 114 114,115 Europes environment: the second assessment. Transport in figures: site on transport data for the Member States Towards sustainable transport in the CEI countries. European report Archives of the centre for sensory research Guidelines for community noise Concern for Europes Tomorrow. Health and the environment in the WHO European Region. Europes environment. Noise news international Fighting noise in the 1990s. Journal of environmental psychology 1997 statistics of road traffic accidents in Europe and North America. Transport in figures statistical pocketbook. Statistical report on road accidents in 1992. Safety of vulnerable road users Road transport and health. A strategic road safety plan for the European Union. IATSS research In: Contributions to the Symposium Reducing Alcohol related Crashes The Role of the European Union. Speed, speed limits and accidents. In: Health at the cross roads. Reducing traffic injuries resulting from excess and inappropriate speed. Driving speeds and pedestrian safety: a mathematical model. European EpiMarker The role of the drinking driver in traffic accidents. Accident analysis and prevention In: Contributions to the Symposium Reducing Alcohol related Crashes The Role of the European Union. Communication from the Commission to the Council, the European Parlia ment, the Economic and Social Committee and the Committee of the Regions: promoting road safety in the European Union: the programme for 19972001. Low cost road and traffic engineering Measures for casualty reduction. Road transport research. Targeted road safety programmes. H EALTH 21. The health for all policy framework for the WHO European Region. Vision Zero in perspective of global generalization Road transport research. Integrated strategies for safety and environment. Update and revision of the air quality guidelines for Europe : meeting of the working group classical air pollutants, Bilthoven, The Netherlands, 1114 October 1994. American journal of respiratory critical care medicine New England journal of medicine American journal of public health Diesel exhaust: a critical analysis of emissions, exposure and health effects. A special report of the Institutes Diesel Working Group. Toxic air contaminant emissions for diesel fueled engines Overview of the environment and health in Europe in the 1990s: Third Ministerial Conference on Envi ronment and Health, London, 1618 June 1999 Review of environmental health Occupational environmental health Air quality criteria for particulate matter. Lancet Occupational and environmental medicine In: Basic documents Journal of the American Medical Association Pediatrics Neurotoxicology and teratology British journal of industrial medicine Psychopathology Medical journal of Australia Psychiatry, psychology and law British medical journal American journal of community psychology Accident analysis and prevention Driving passion. Road rage. Death on the road: a study in social violence. Environmental psychology Behaviour and experience in context. Journal of the American Institute of Planners Journal of public health medicine Childrens environ ments The well being of Canadians: highlights of the 1988 Campbells survey. Preventive medicine Physical activity and health: a report of the Surgeon General. Sports medicine Patient education and counseling Physical activity in transport: value for health. Cycling: towards health safety. Medicine and science in sports and exercise Journal of the American Medical Association WALCYNG: how to enhance walking and cycling instead of short car trips and to make these modes safer. Henkilliikennetutkimus 1992 The global burden of disease: a comprehensive assessment of mortality and disability from diseases, injuries and risk factors in 1990 and projected to 2020: a summary edited by Christopher J.L. Murray, Alan D. Lopez. Medicine and science in sports and exercise Pyrilyn edistminen vuosina 19972005 Walking and cycling in the city. The true costs of transport. Science of the total environment Epidemiology Epidemiology Occupational and environmental medicine Archives of environmental health Annals of epidemiology Science of the total environment Linking road traffic accident statistics to census data in Lothian. Archives of disease in childhood Social science and medicine Interna tional journal of epidemiology American journal of epidemiology British medical journal International archives of occupational and environmental health Road user exposure to air pollution: literature review. Occupational and environmental medicine American journal of public health American review of respiratory diseases Recent studies on the community noise response in Spain. Journal of sound and vibration Environmental problems in Norway. Pedestrian activity and accident risk. Journal of epidemiology and community health Attitudes to cycling: a qualitative study and conceptual framework. Accident analysis and prevention Young people and physical activity: a literature review. Journal of epidemiology and community health International journal of aging and human development Older people on foot why we must act. Uses and abuses of transport and road safety statistics in policy formulation. Quantifica tion of the effects of air pollution on health in the United Kingdom. Inequalities in health: the Black report. Tackling inequalities in health: an agenda for action. External costs of transport accidents, environmental and congestion costs in western Europe. Health costs due to road traffic related air pollution. An impact assessment project of Austria, France and Switzerland. Economic evaluation. Technical report on economy inter alia This Annex is a complete inventory of all international actions developed in the fields of Trans port, Environment and Health. It has been developed as a living document, open to further improvements. It is meant solely to provide readers of the Charter on Transport, Environment and Health with a list of iden tified relevant references. Air pollution Environmental impact assessment Public information and participation Transport of dangerous goods Transport of perishable foodstuffs Road traffic and road signs and signals Road vehicles Transport infrastructures Working conditions Taxation Private law Economic regulations Inland navigation Water protection Rail transportation Climate change Protection of the ozone layer Transboundary movements of hazardous wastes and chemicals Environmental impact assessment Road safety Driving licences Air quality Noise Two or three wheel motor vehicles Inland waterways Maritime safety and protection of the marine environ ment Maritime safety Marine pollution Liability and compensation Other subjects Air quality guidelines Sustainability. The precautionary principle. Prevention of transport related adverse health effects. Protection and promotion of health. The polluter pays principle, including the internali zation of externalities Multisectoral integration. Equity. Public participation and information. Subsidiarity. Efficiency. Air quality guidelines Air quality guidelines #font 284 "Frutiger BlackItalic 272 0" Foreword Foreword #font 267 "Frutiger Black 307 0" T R A N S P O R T , E N V I R O N M E N T A N D H E A L T H 2 Acknowledgements 3 Contributors T R A N S P O R T , E N V I R O N M E N T A N D H E A L T H 4 F O R E W O R D 5 T R A N S P O R T , E N V I R O N M E N T A N D H E A L T H 6 Introduction Traffic threatens health. TCL ICP Milano I N T R O D U C T I O N 7 Fig. 1. Increasing use of cars in Europe compared with other modes of transport, 19701997 Source: Fig. 2. Modes of passenger travel in Europe, 1995 Source: T R A N S P O R T , E N V I R O N M E N T A N D H E A L T H 8 T R A N S P O R T N O I S E 9 Disturbed sleep Difficulties with performance 1. Transport noise: a pervasive and underestimated ambient stressor Noise impairs communication. The health effects of noise Impaired communication TCL ICP Milano T R A N S P O R T , E N V I R O N M E N T A N D H E A L T H 10 Annoyance Increased aggression Heart disease and hypertension Hearing impairment Fig. 3. Families severely annoyed by daytime noise in Basle, Switzerland, 1980s Source: T R A N S P O R T N O I S E 11 Guideline values and how Europe matches up Intervention Emission control Changing traffic Insulation Intervention effectiveness T R A N S P O R T , E N V I R O N M E N T A N D H E A L T H 12 Table 1. Guideline values for community noise in specific environments Source: T R A N S P O R T N O I S E 13 Policy considerations T R A N S P O R T , E N V I R O N M E N T A N D H E A L T H 14 Moped riders suffer high death rates from accidents. 2. Transport accidents and injuries Interpreting risks Levels, trends and risks Cristina Piza Lopez A C C I D E N T S A N D I N J U R I E S 15 Victims of traffic accidents Fig. 4. Average standardized death rates from road traffic accidents per 100 000 population Source: T R A N S P O R T , E N V I R O N M E N T A N D H E A L T H 16 Where accidents happen Doseresponse relationships Speed Alcohol The effectiveness of preventive strategies Roads are high risk areas for children. TCL ICP Milano A C C I D E N T S A N D I N J U R I E S 17 Setting targets for road safety Table 2. Effectiveness of various measures to prevent traffic injuries Source: T R A N S P O R T , E N V I R O N M E N T A N D H E A L T H 18 Conclusions for policy A I R P O L L U T I O N 19 3. Serious health impact of air pollution generated from traffic Pollutants and effects Particulate matter Traffic generated air pollution. Marco Pierfranceschi T R A N S P O R T , E N V I R O N M E N T A N D H E A L T H 20 Which component is responsible? Other independent effects Carcinogens Climate change A I R P O L L U T I O N 21 Role of traffic generated air pollution Fraction of air pollutants from traffic Trends in traffic related pollution exposure Fig. 5. Levels and changes in concentrations of suspended particulate matter in European cities, 1990s Source: T R A N S P O R T , E N V I R O N M E N T A N D H E A L T H 22 Human exposure Determinants of traffic generated air pollutants Estimates of the impact on health A I R P O L L U T I O N 23 Direct link between proximity to heavy traffic and ill health Policy implications T R A N S P O R T , E N V I R O N M E N T A N D H E A L T H 24 E F F E C T S O N M E N T A L H E A L T H 25 4. The effects of transport on mental health and wellbeing Effects of lead Posttraumatic stress from accidents T R A N S P O R T , E N V I R O N M E N T A N D H E A L T H 26 Effects of traffic Aggression and nervousness Reduced social life E F F E C T S O N M E N T A L H E A L T H 27 Constraints on child development Table 3. Road traffic and networks of social support Source: T R A N S P O R T , E N V I R O N M E N T A N D H E A L T H 28 Mental health benefits of exercise Fig. 6. The effects of ever increasing traffic on childrens freedom of movement Source: E F F E C T S O N M E N T A L H E A L T H 29 Conclusion T R A N S P O R T , E N V I R O N M E N T A N D H E A L T H 30 5. Cycling and walking for transport Effects of cycling and walking on health Cycling can benefit human and environmental health. Cristina Piza Lopez C Y C L I N G A N D W A L K I N G 31 How much physical activity is required for health gains? Trends in cycling and walking T R A N S P O R T , E N V I R O N M E N T A N D H E A L T H 32 Potential health benefits from increasing cycling and walking Policy issues Promoting physical fitness through cycling and walking for transport Including the health benefits of cycling and walking in assessment of transport policies Fig. 7. Number of trips made by different means of transport over different distances Source: C Y C L I N G A N D W A L K I N G 33 Improving monitoring of physically active transport Conclusion T R A N S P O R T , E N V I R O N M E N T A N D H E A L T H 34 6. Groups at higher risk of the damaging health effects of transport Greater health risks in urban areas Greater suffering for the less affluent Traffic injury G R O U P S A T H I G H E R R I S K 35 Traffic and exercise Air pollution Noise Residence as a factor T R A N S P O R T , E N V I R O N M E N T A N D H E A L T H 36 Risks depending on gender and age Women Children Elderly people G R O U P S A T H I G H E R R I S K 37 Vulnerable road users Conclusion T R A N S P O R T , E N V I R O N M E N T A N D H E A L T H 38 P O L I C Y F R A M E W O R K 39 7. Policy framework Why governments need to intervene What governments could do General principle: the cost creator pays Table 4. The external costs of transport in the EU, Norway and Switzerland, 1995 Source: T R A N S P O R T , E N V I R O N M E N T A N D H E A L T H 40 Pollution Governments should intervene. Marco Pierfranceschi P O L I C Y F R A M E W O R K 41 Accidents Information to change preferences T R A N S P O R T , E N V I R O N M E N T A N D H E A L T H 42 Government investment Investment in research and technology Effects to be further clarified P O L I C Y F R A M E W O R K 43 Health impact assessment Valuing benefits in economic terms T R A N S P O R T , E N V I R O N M E N T A N D H E A L T H 44 The challenge of economic valuation Conclusions C O N C L U S I O N S 45 Conclusions Failure to integrate health considerations into transport decisions Isolated responses T R A N S P O R T , E N V I R O N M E N T A N D H E A L T H 46 Strategies for change C O N C L U S I O N S 47 The future: healthy transport? Le Immagini Fotografia, Ferrara T R A N S P O R T , E N V I R O N M E N T A N D H E A L T H 48 References R E F E R E N C E S 49 T R A N S P O R T , E N V I R O N M E N T A N D H E A L T H 50 R E F E R E N C E S 51 T R A N S P O R T , E N V I R O N M E N T A N D H E A L T H 52 R E F E R E N C E S 53 T R A N S P O R T , E N V I R O N M E N T A N D H E A L T H 54 C H A R T E R 55 Annex 1. Charter on Transport, Environment and Health 1 Reference is made to the supportive statement of the European Commission EC in the Declaration of the Third Ministerial Conference on Environment and Health EUR ICP EHCO 02 02 05 18 Rev.5 . Preamble T R A N S P O R T , E N V I R O N M E N T A N D H E A L T H 56 I. Why health is an issue in transport and environment policies: the concerns II. What has happened so far: the state of play C H A R T E R 57 III. Where do we want to go: principles, approaches and guiding strategies for transport sustainable for health and the environment T R A N S P O R T , E N V I R O N M E N T A N D H E A L T H 58 IV. How will the goals be achieved: a plan of action for moving towards transport sustainable for health and the environment A. Integration of environment and health requirements and targets in transport and land use policies and plans C H A R T E R 59 B. Promotion of modes of transport and land use planning which have the best public health impacts T R A N S P O R T , E N V I R O N M E N T A N D H E A L T H 60 C. Health and environmental impact assessments D. Economic aspects of transport, environment and health E. Special care of groups at higher risk C H A R T E R 61 F. Risks to public health not yet clearly quantified T R A N S P O R T , E N V I R O N M E N T A N D H E A L T H 62 G. Indicators and monitoring H. Pilot actions and research I. Public participation, public awareness, information C H A R T E R 63 J. Countries in transition and countries with severe problems concerning transport related health effects V. Implementation and follow up process T R A N S P O R T , E N V I R O N M E N T A N D H E A L T H 64 C H A R T E R 65 T R A N S P O R T , E N V I R O N M E N T A N D H E A L T H 66 Annex 1. Evidence for the links between transport, environment and health 2 key facts and figures 2 The evidence provided in Annex 1 is based on expertise brought together by WHO, in particular through the work of the scientific experts who prepared the summary substantiation paper and the book Transport, environment and health, where a detailed discussion of the issues and literature references are presented. The summary substantiation paper and the book will be issued at the time of the Third Ministerial Conference on Environment and Health, and can be ordered from WHO. The summary substantiation paper can also be downloaded from the Internet at www.who.dk london99. Transport accidents Air pollution Traffic noise C H A R T E R 67 Physical activity Psychosocial effects T R A N S P O R T , E N V I R O N M E N T A N D H E A L T H 68 3 Turkey has a reservation on the Conventions and Agreements to which it is not a signatory party. Water and soil pollution Groups at higher risk Annex 2. Relevant international actions status as of March 1999 Legally binding documents 3 C H A R T E R 69 T R A N S P O R T , E N V I R O N M E N T A N D H E A L T H 70 C H A R T E R 71 United Nations United Nations Environment Programme UNEP European Union EU T R A N S P O R T , E N V I R O N M E N T A N D H E A L T H 72 C H A R T E R 73 T R A N S P O R T , E N V I R O N M E N T A N D H E A L T H 74 International Civil Aviation Organization ICAO OACI International Maritime Organization IMO C H A R T E R 75 Not legally binding documents World Health Organization WHO T R A N S P O R T , E N V I R O N M E N T A N D H E A L T H 76 European Union EU International Union of Railways UIC European Civil Aviation Conference ECAC International Maritime Organization IMO European Conference of the Ministers of Transport ECMT Resolutions C H A R T E R 77 Organisation for Economic Co operation and Development OECD United Nations Economic Commission for Europe UN ECE United Nations Conference on Environment and Development UNCED United Nations Centre for Human Settlements UNCHS Central European Initiative CEI United Nations Environment Programme UNEP European Sustainable Cities and Towns T R A N S P O R T , E N V I R O N M E N T A N D H E A L T H 78 4 These definitions have been developed specifically for the purpose of this Charter. Annex 3. Description of principles, approaches and guiding strategies for transport sustainable for health and the environment Principles and approaches 4 C H A R T E R 79 Guiding strategies T R A N S P O R T , E N V I R O N M E N T A N D H E A L T H 80 Annex 4. Health targets for transport, environment and health Air quality Traffic deaths and serious injuries Promoting cycling and walking for physical activity Noise C H A R T E R 81 Acknowledgements Sw.fr. 35. ISBN 92 890 1356 7 #font 254 "AGaramond Bold 283 0" World Health Organization 2000 2173 2 6 1 22 26 151 329 85 13 54 356 55 263 91 15 50 23 159 2 317 18 9 38 18 12 17 23 33 30 273 26 189 190 8 7 53 49 4 169 68 33 24 132 314 67 54 85 145 132 43 46 36 We will implement We call on WHO to: #font 247 "AGaramond Italic 312 0" Text editing: Design layout: Cover photo: Foreword.......................................................... Foreword.......................................................... #font 39 "AGaramond Regular 310 0" The World Health Organization was established in 1948 as a specialized agency of the United Nations serving as the directing and coordinating authority for international health matters and public health. One of WHOs constitutional functions is to pro vide objective and reliable information and advice in the field of human health, a responsibility that it fulfils in part through its publications programmes. Through its publications, the Organization seeks to support national health strategies and address the most pressing public health concerns. The WHO Regional Office for Europe is one of six regional offices throughout the world, each with its own programme geared to the particular health problems of the countries it serves. The European Region embraces some 870 million people living in an area stretching from Greenland in the north and the Mediterranean in the south to the Pacific shores of the Russian Federation. The European pro gramme of WHO therefore concentrates both on the problems associated with industrial and post industrial society and on those faced by the emerg ing democracies of central and eastern Europe and the former USSR. To ensure the widest possible availability of authori tative information and guidance on health matters, WHO secures broad international distribution of its publications and encourages their translation and adaptation. By helping to promote and protect health and prevent and control disease, WHOs books contribute to achieving the Organizations principal objective the attainment by all people of the highest possible level of health. edited by Carlos Dora and Margaret Phillips WHO Library Cataloguing in Publication Data Transport, environment and health edited by Carlos Dora and Margaret Phillips WHO regional publications. European series ; No. 89 1.Environmental health 2.Transportation 3.Environmental policy 4.Accidents, Traffic 5.Vehicle emissions adverse effects I.Dora, Carlos II.Phillips, Margaret III.Series ISBN 92 890 1356 7 NLM Classification: WA 810 ISSN 0378 2255 Mary Stewart Burgher Susanne Christensen, In House Christina Piza Lopez ISBN 92 890 1356 7 ISSN 0378 2255 The Regional Office for Europe of the World Health Organiza tion welcomes requests for permission to reproduce or translate its publications, in part or in full. Applications and enquiries should be addressed to the Publications unit, WHO Regional Office for Europe, Scherfigsvej 8, DK 2100 Copenhagen , Denmark, which will be glad to provide the latest information on any changes made to the text, plans for new editions, and reprints and translations already available. Publications of the World Health Organization enjoy copyright protection in accordance with the provisions of Protocol 2 of the Universal Copyright Convention. All rights reserved. The designations employed and the presentation of the mate rial in this publication do not imply the expression of any opin ion whatsoever on the part of the Secretariat of the World Health Organization concerning the legal status of any country, terri tory, city or area or of its authorities, or concerning the delimi tation of its frontiers or boundaries. The names of countries or areas used in this publication are those that obtained at the time the original language edition of the book was prepared. The mention of specific companies or of certain manufacturers products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. The views expressed in this publication are those of the author and do not necessarily represent the decisions or the stated policy of the World Health Organization. PRINTED IN AUSTRIA Acknowledgements..........................................2 Contributors....................................................3 4 5 Introduction....................................................6 1.Transport noise: a pervasive and underestimated ambient stressor.................9 2. Transport accidents and injuries..................14 3. Serious health impact of air pollution generated from traffic..................................19 4. The effects of transport on mental health and wellbeing..............................................25 5. Cycling and walking for transport...............30 6. Groups at higher risk of the damaging health effects of transport............................34 7. Policy framework.........................................39 Conclusions.....................................................45 References........................................................48 Annex 1. Charter on Transport, Environment and Health.................................55 This review was prepared and produced with the support of the Regional Office for Europe of the United Nations Environmental Programme UNEP , the European Environment Agency EEA and the Austrian Federal Ministry of Agriculture, Forestry, Environment and Water Management. The WHO Regional Office for Europe thanks all countries, organizations and people that have sup ported and contributed to this work. In particular, WHO thanks the Austrian Federal Ministry of Ag riculture, Forestry, Environment and Water Man agement, especially Robert Thaler, head of its Transport, Mobility, Regional Planning and Noise Division, for providing resources. Jutta Molterer, of the Ministrys Transport, Mobility, Regional Plan ning and Noise Division, and Maria Teresa Marchetti, of the Rome division of the WHO Eu ropean Centre for Environment and Health, pro vided invaluable managerial and administrative support, and Francesca Racioppi, also of the Rome division, contributed to the revision of the manu script. Thanks are also due to Professor John Adams, of the Geography Department, University College London, United Kingdom; Mr David Gee, of the Integrated Assessment Programme, European En vironment Agency, Copenhagen, Denmark; and Professor John Whitelegg, Managing Director, Ecologica Ltd, United Kingdom. Dr U. Ackermann Liebrich University of Basel, Switzerland Professor Birgitta Berglund University of Stockholm, Sweden Professor Bert Brunekreef Wageningen Agricultural University, Netherlands Mr Adrian Davis Consultant on transport and health Bristol, United Kingdom Mr W. Richard Dubourg University College London, United Kingdom Dr Hans Eerens National Institute of Public Health and the Environment RIVM , Bilthoven, Netherlands Dr Rainer Fehr Landesinstitut fr den Offentlichen Gesundheitsdienst NRW, Bielefeld, Germany Dr Antje Flade Institute for Housing and Environment, Germany Dr Tony Fletcher London School of Hygiene and Tropical Medicine, United Kingdom Dr Francesco Forastiere Department of Epidemiology, Lazio Regional health Authority, Rome, Italy Dr Hermann Knoflacher Technical University of Vienna, Austria Dr W. Kofler University of Innsbruck, Austria Dr E. Lebret National Institute of Public Health and the Environment RIVM , Bilthoven, Netherlands Dr Peter Lercher Institute of Social Medicine, University of Innsbruck, Austria Dr Michael Lipsett University of California, San Francisco, California Dr Beate Littig Department of Sociology, Institute for Advanced Studies, Austria Dr David Maddison University College London, London, United Kingdom Ms Maria Teresa Marchetti Secretary, Epidemiology, WHO European Centre for Environment and Health, Rome, Italy Ms Jutta Molterer Federal Ministry of Agriculture, Forestry, Environment and Water Management, Vienna, Austria Dr Gerd Oberfeld Head, Environmental Medicine, Austrian Medical Association, Salzburg, Austria Dr Pekka Oja Urho Kaleva Kekkonen Institute Tampere, Finland Ms Margaret Phillips Health Economist Cambridge, United Kingdom Ms Francesca Racioppi WHO European Centre for Environment and Health, Rome, Italy Dr Eliu Richter Hebrew University of Jerusalem, Israel Ms Lilo Schmidt SoMo Consultancy, Austria Mr Robert Thaler Federal Ministry of Agriculture, Forestry, Environment and Water Management, Vienna, Austria Professor Ilkka Vuori Urho Kaleva Kekkonen Institute Tampere, Finland Marc Danzon WHO Regional Director for Europe Wilhelm Molterer Austrian Federal Minister of Agriculture, Forestry, Environment and Water Management pollutants in Europe are estimated to have a major impact on mortality, resulting in 40 000130 000 deaths a year in urban adults. Most human expo sure from air pollutants comes from traffic, and evi dence is emerging of a direct link between respiratory problems and residence near busy roads, or roads with much heavy vehicle traffic. Around 65 of the people in the Region are exposed to lev els of noise leading to sleep dis turbance, speech interference and annoyance, and road traf fic provides most human expo sure to noise. So far, no one has quantified the impact of the restricted op portunities for cycling and walking brought about by cur rent policies on urban land use planning and trans port, but the effect of sedentary lifestyles on heart disease is similar to that of tobacco. Half the adult population in developed countries is sedentary or does minimal physical activity. One could therefore speculate that barriers to physical activity might have the greatest impact of all traffic related health risks. Attempts to assess the concomitant effects of sev eral transport related risks have been incomplete. For example, the calculations have not considered the health gains from strategies that increase walk ing and cycling. Certain transport and land use policies protect the environment and promote public health. These in teractions need to be identified and emphasized; they are often overlooked. The effectiveness of interven tions is often assessed on the basis of a single health Many countries in Europe face the apparently con flicting needs of transport policies. Transport facili tates access to jobs, education, markets, leisure and other services, and has a key role in the economy. On the other hand, concern is mounting about the detrimental impact on the environment of current transport policies, and many people question the policies social sustainability. In addition, the effects on hu man health of transport and land use strategies are increas ingly widely recognized. While injuries and annoyance from traffic noise have long been identified as important conse quences of certain patterns of transport activities, evidence of a direct effect of air pollutants on mortality and respiratory and cardiovascular diseases has emerged only in the last few years. The wide range and seriousness of the anticipated health effects of climate change are increasingly evident. Further, sed entary lifestyle, one of the two most important risk factors for noncommunicable diseases and early mortality in populations in western countries, is associated with the use of motor vehicles. It is now acknowledged that strategies to address it require physical activity to accomplish daily chores, nota bly through walking and cycling for transport. Each of these transport related risks imposes a con siderable burden on public health. Even if average death rates for road accidents have been gradually decreasing, traffic accidents still cause 120 000 deaths a year in the WHO European Region, a third of them in people under 25. There is an eightfold difference between the countries with the highest and lowest rates. In addition, current levels of air outcome. In view of the wide range of possible ef fects, some beneficial, some not, such narrow as sessments may give misleading results. For example, some policies improve one health aspect to the det riment of another. Lowering speed limits may re duce accidents but increase pollution. The legal requirement for cyclists to use helmets in Australia reduced head injuries, but also reduced the number of cyclists to a point that net health losses are ex pected. Motorways are safer than smaller roads, but the high speed that they allow has a spillover effect, increasing risks on smaller roads. The continuing expansion of motorized transport in Europe today Fig. 1 raises crucial questions about the efficiency and the environmental and so cial implications of land use and transport policies . For example, in the countries of central and eastern Europe, public transport still satisfies a rela tively large share of the transport demand Fig. 2 , but the sharp increase in the use of private cars raises concerns about the sustainability of transport sys tems in these countries . Health arguments are central to this debate, but these are often articu lated in very limited ways. Public policies, such as transport and land use policies, clearly need assess ment with a wide public health perspective. The challenge is to promote healthy and sustain able transport alternatives to prevent the negative effects of transport systems on human health. An important way to do this is to ensure that health issues are clearly on the agenda when transport de cisions are being made and policies formulated. One reason this has not always happened is that the ana lytical tools required have been unavailable, inad equate or poorly understood. Methodologies need to be developed, promoted and used to make inte grated assessments, monitor progress, account fully for social and environmental costs and identify the strategies with the greatest net benefits. The inte gration of health, environment and other social con cerns into transport policies requires high level political commitment to intersectoral cooperation, and to a change in current strategies towards full consideration of the implications of transport policy for development, the environment and health. This book contains some of the key facts that sub stantiate the political commitment and momentum for action to support transport that is sustainable for health and the environment. This commitment is set out in the Charter on Transport, Environment and Health Annex 1 , adopted at the WHO Third Ministerial Conference on Environment and Health, in London in June 1999. The Charter includes quan titative health targets for transport systems for the WHO European Region, strategies to achieve them and mechanisms for monitoring progress. A major purpose of this book is to alert policy ana lysts, decision makers and politicians to current knowledge about the health effects of transport and the means to reduce them. It summarizes the latest scientific evidence on the impact of transport in duced air pollution, noise and accidents on physi cal health, barrier effects changes in behaviour in reaction to transport risks and effects on mental health. This book highlights the considerable po tential health benefits from non motorized forms of transport. It is based on extensive reviews com missioned for the London Conference, which in clude not only the reviews but also a historical analysis of transport related health policies, case studies from European cities and a discussion of equity implications. intelligible. In classrooms and meeting rooms used by elderly people, hearing impaired individuals or children who are especially sensitive to the health impacts of noise , background noise should be 10 dB LAeq below that of the speaker. Noise can cause difficulty in falling asleep, reduc tion in deep resting sleep, increased awakenings during sleep and adverse after effects such as fatigue and decreased performance. These effects are avoided if noise levels are kept below 30 dB LAeq continu ous noise or 45 dB LAmax indoors. LAeq values refer to steady state continuous noise. LAmax val ues refer to noise events. Children chronically exposed to aircraft noise show impaired reading acquisition, attention and prob Transportation is the main source of noise pollu tion in Europe, and road traffic, the major cause of human exposure to noise, except for people living near airports and railway lines. Ambient sound lev els have steadily increased, as a result of the growing numbers of road trips and kilometres driven in motor vehicles, higher speeds in motor vehicles and the increased frequency of flying and use of larger aircraft. Noise is a problem in Europe; it is the only environmental factor for which complaints have increased since 1992 . The scientific evidence on the health effects of noise is growing. After its first scientific review of this evi dence in 1980, WHO convened an international task force that assessed new evidence and set the basis for this summary and the WHO guidelines for community noise . Good evidence shows the adverse effects of noise on communication, school performance, sleep and temper, as well as cardiovascular effects and hearing impairment. Speech is 100 intelligible with background noise levels at 45 dB LAeq. Above 55 dB LAeq background noise the level of an average female voice the voice has to be raised. Such background levels interfere with concentration and the raised voice becomes less lem solving ability. Noise can interfere with mental activities requiring attention, memory and ability to deal with complex analytical problems. Adapta tion strategies, such as tuning out and ignoring noise, and the effort needed to maintain performance have been associated with high blood pressure and el evated levels of stress hormones. Annoyance response broadly increases with sound level, with most people being moderately annoyed at 50 dB LAeq and seriously annoyed at 55 dB Laeq Fig. 3 . Only one third of variation in annoyance is due to sound levels; a number of other factors affect the response to noise. The most annoying types of noise come from aircraft, have low frequency components or are accompanied by vibration, and interfere with social and economic activity. In addi tion, geographic factors affect vulnerability to noise; in the Alps, for example, topography, background levels of noise and acoustic factors of the slopes all influence the effect of a given level of noise. Loud noise increases aggressive behaviour in pre disposed individuals, and levels above 80 dB LAeq reduce helping behaviour peoples willingness and availability to help others . The increasing evidence on ischaemic heart disease and hypertension points to an effect of noise at around 6570 dB LAeq. The effect is small but, since a large percentage of the population is exposed to such levels, it could be of great public health sig nificance. Loud noise can cause hearing impairment, although the risk is considered negligible in the general popu lation for noise levels below 70 dB Laeq over 24 hours over a period of 40 years. Since the environment, time of day and context influence the impact of noise, a variety of different guideline values for community noise exposure have been proposed ; WHO values are summa rized in Table 1. A very high and increasing proportion of the popu lation of the WHO European Region is exposed to unacceptable levels of noise. The proportion exposed to noise levels greater than 65 dB LAeq over 24 hours has risen from 15 in the 1980s to 26 in the 1990s . About 65 of the European population 450 million people is exposed to sound levels 55 65 dB LAeq over 24 hours that cause serious an noyance, speech interference and sleep disturbance . Some Member States are already monitoring noise and setting limits on noise pollution in sensitive areas. The European Union EU is developing a framework directive for noise that takes account of the evidence on health impacts and the available technology. The proposed WHO community noise guideline levels provide a useful intermediate target for coun tries. Adherence to these guidelines would give di rection and focus to countries efforts to address the important problem of traffic induced noise. Technological improvements, such as low noise road surfaces and vehicles particularly tyres on cars , have the potential to help manage the traffic noise prob lem. The technology is available and has been evalu ated, but needs appropriate promotion, regulation and enforcement through, for example, the inclu sion of spot and yearly testing of noise as part of tests of vehicle road worthiness, and taxes on noisy vehicles or aircraft. Controls on speed through the establishment and policing of speed limits and traffic calming measures, for example are another way to control noise emissions at source. Unfortunately, reliance on emission control alone in the last few decades has not reduced sound lev els. Instead, the growth and spread of traffic have offset these technological improvements , and road, air and rail traffic are all forecast to continue increasing. Reducing the overall amount of traffic or at least its growth is almost certainly necessary to control the health effects of noise emissions from traffic. This will be particularly important in popu lated areas located near zones of very heavy traffic, such as airports, highways, high speed train tracks and heavy vehicle transit routes. In addition, measures to alter the composition and timing of traffic such as restrictions during nights and weekends, zoning and flight corridors and its location in relation to people such as the use of flyovers, tunnels, rerouting, green spaces and road barriers can mitigate the impact of traffic noise. Who experiences the noise, and where and when are crucial in determining its health impact. Further, the impact of noise can be modified through noise insulation in the construction and design of buildings. Examples include using particular types of windows and roofs and the locating of bedrooms at the rear of buildings, away from noise sources. Many of these approaches have been practised, though not systematically. With the exception of emission control technologies, they have rarely been evaluated. Evaluations should examine not just acoustically measured noise but also health out comes. A rare example of such an approach is Bronzafts study of the effect of a noise abate ment programme on reading ability. Acoustic meas ures are much easier to make, but interpreting their significance is difficult because their relationship to health is complex. All measures taken to abate noise and reduce expo sure and related health effects need to consider the following dimensions: specific environments where people function, such as schools, playgrounds, homes and hospitals, all of which have special and somewhat different re quirements for noise limits that vary with time night, weekends, holidays and evenings are par ticularly sensitive periods in some environments ; environments with multiple noise sources or with conditions that amplify the effects of noise, which require land use and transport planning to be car ried out with special care; and groups at high risk of health effects from trans port noise, such as children and people who are elderly, hearing impaired or ill. Well directed research, monitoring and information dissemination are urgently needed to accompany action for traffic noise reduction. Substantial im provements are needed in knowledge of human ex posure to noise in various environments: both the levels of noise and the effects of exposure on health. Monitoring of human exposure needs to be routine and to use standard methods to facilitate compari sons. Sound levels should be available for dwellings, schools, hospitals, workplaces, playgrounds and parkland. Groups at higher risk of noise effects should be addressed specifically. Special attention should be given to monitoring populations exposed to more than one noise source. Night time as well as daytime values should be measured. At present, night time levels of ambient noise are particularly poorly documented. There is a danger that proposed shifts of heavy volumes of freight or aircraft traffic to the night could produce considerable health ef fects that current monitoring procedures would not capture. Surveillance and periodic evaluations should be car ried out of noise related adverse health effects such as reduced speech intelligibility, sleep disturbance and annoyance in areas where these can be expected. The information gained should be used, in conjunc tion with noise exposure data, to assess the effec tiveness of noise reduction measures. Data on exposure and health effects should be made available in formats useful for policy making. For example, maps to identify areas with greater expo sure can be made; these can then be used in envi ronmental health impact assessments to influence decisions on transport and land use planning. According to the health for all database of the WHO Regional Office for Europe, mortality caused by road transport in the European Region shows more than an eightfold difference between countries with the lowest and highest rates per head of population. The Baltic countries, the Russian Federation and some southern countries Portugal and Greece report the highest figures, thus indicating the greatest poten tial for improvement. Within the EU, there is an approximately fourfold difference between countries with the lowest and highest death rates. Across the Region, mortality rates for traffic acci dents fell in the 1990s, but this decline obscures the sharp increase in mortality in the eastern countries in the early 1990s Fig. 4 , following very substan tial increases in road traffic and the number of new and inexperienced drivers. In spite of some improve ments in more recent years, average rates in the newly independent states of the former USSR are still about 1.5 times those in the EU. Accident rates are usually expressed in terms of p km or vehicle kilometres. There is, however, a case for replacing these with an indicator based on the rate of accidents per trip. Securing access to goods, services, jobs, other people and amenities is, after all, the function of transport. Interestingly, the number of trips and the time spent travelling have remained quite constant over time in most coun tries. What has changed is the distance and speeds travelled per trip; both have increased. Using indi cators of risk per kilometre thus gives the mislead ing impression that the accident risk of road travel is decreasing faster than it actually is. Society tolerates a disturbingly high level of risk from motorized transport. In 1995, around 2 million road traffic accidents with injuries were reported in the WHO European Region, resulting in about 120 000 people killed and 2.5 million injured; road traffic accidents were responsible for about 44 000 deaths and 1 500 000 casualties in the EU . Road accidents account for the most significant share of all transport accidents, in terms both of the number of deaths and of death rates per kilometre travelled. In the EU, almost 50 times as many peo ple die on the roads as in rail accidents 44 000 and 936 deaths, respectively, in 1995 . This is only partly explained by the higher passenger kilometres p km travelled by road: death rates are about three times higher for road than for rail transport 11.1 versus 3.4 deaths per 1 billion p km . The number of deaths by air or sea travel is much lower. Air accidents involving scheduled flights world wide resulted in a total of 916 fatalities in 1997, corresponding to 0.4 fatalities per 1 billion p km; the figure for sea travel was 690 in 1996 . Although the drivers and occupants of motor vehi cles comprise over 60 of the people killed or in jured on the road , others suffer a very significant proportion of deaths and injuries. Pedestrians ac count for around 2530 of deaths and 13 of injuries, and cyclists, 56 of deaths and 78 of injuries . Cyclists suffer more fatal accidents than pedestrians in countries, such as the Nether lands, where cycling is common . The severity of accidents the number of deaths per total number of accidents with injuries is almost twice as high for pedestrians as for car occupants . The term vulnerable road users all too accurately de scribes those who cycle and walk see Chapter 6 . The absolute number of pedestrian fatalities has decreased over the last three decades , but this is probably less a function of reduced risk for pedestrians than a consequence of a fall in expo sure; pedestrians walk less often and less far than before. For example, the United Kingdom has re ported a 17 decline in miles walked between 1975 1976 and 1994 , probably due in part to the fear of accidents. Of all vehicle occupants, moped riders and motor cyclists report the highest death rates, both per mil lion vehicles and per p km . British statistics for 19831993 show that, on average, death rates per p km were around 24 times higher for motor cyclists than for car occupants . One in every three people killed on the road is younger than 25 years . The risk of being in volved in a light or serious accident is five times higher for learner drivers aged 1819 years than for experienced drivers older than 25 years . Alco hol and drug use are factors that further increase the risk in young drivers . The risk of accidents varies, depending on the type of road, the traffic mix, the time of day and climatic conditions, and the speed and mass of vehicles in volved. On average, around 65 of road accidents happen in built up areas, 30 outside built up areas and around 45 on motorways. In most countries, however, the risk of dying in accidents occurring on motorways is two to three times higher than those on other roads , very often be cause of the higher speed driven on motorways. Roads near houses and schools are high risk areas for children, and restrict their activity, including cycling and walking. Parents report the fear of acci dents as the main reason for escorting children to school . The areas of highest risks for vulner able road users such as pedestrians and cyclists are minor roads and their intersections with arterial roads . Average speeds have a strong link with accident rates. In general, a 1 km per hour reduction in average speed results in about a 3 reduction in the number of accidents . Speed also affects accident se verity, particularly for vulnerable road users: the risk of death for a pedestrian is about eight times higher in a collision at 50 km per hour than one at 30 km . Allowing faster speeds on some roads appears to have a spillover effect elsewhere; the average speed of the entire road system increases, thereby further increasing the risk of accidents . Several studies have demonstrated that increased blood alcohol concentration is related to an increase in the relative risk of accidents . Any detect able level of alcohol in the blood results in a higher risk of accident involvement. This risk is about 40 higher at a blood alcohol concentration of 0.5 g litre than at zero; with concentrations over 1.0 g litre, there is about a tenfold increase . Current strategies to prevent traffic injuries have reduced traffic mortality where implemented, and further progress could be achieved by introducing or improving the enforcement of several low cost and cost effective measures. Table 2 summarizes information on the effectiveness of several preven tive measures . Other measures can also be effective. For example, road design is important, and such features as ap propriately placed roundabouts, traffic calming in residential areas and cycling paths can all help in reducing accident rates 30 . In addition, the occu pational health standards for the duration of work ing shifts and rest hours of professional drivers could be more strictly applied. International experience shows that setting quanti tative targets in road safety programmes can lead to better programmes and more effective use of re sources . WHO has a regional health target to reduce deaths and injuries from road traffic acci dents by at least 30 by the year 2020 . The EU second community action programme on road safety 19972001 aims to achieve a 30 re duction of traffic fatalities above the results expected following a business as usual approach equivalent to a reduction of nearly 60 from 1995 figures . Employing the assumption that avoidance of one fatal accident in the EU would save ECU 1 million, it identifies a number of cost effective measures af fecting vehicle safety, road infrastructure and driver behaviour to help achieve these goals. Several countries in the Organisation for Economic Co operation and Development OECD have set targets for the reduction of road accidents . Swedens long term goal is that nobody be killed or seriously injured in the road system. This Vision Zero is based on the principle that society should no longer accept deaths and permanent injuries from road accidents. This goal will determine the maxi mum speeds in the system . Far too many people die and are injured on the roads. The effective policies carried out in some countries clearly demonstrate that this can change. What is needed, first and foremost, is the political will to implement and enforce effective preventive meas ures. This requires a radical change in culture, from one of acceptance of road traffic accidents as an unavoidable effect of development towards one of no tolerance towards deaths and serious injuries from accidents. Information, education and communication strat egies have an important role in supporting the pub lic participation, attitudes and behaviour that are essential for the success of new policies. Communi cation and education, however, are no substitutes for other measures, which might include legislation and its necessary adjunct, policing. No matter how well trained, informed or motivated, human beings are prone to error. The design of the environment plays an important part in moderating inappropri ate behaviour. The implementation of measures to reduce deaths and injuries on the road will almost certainly re quire a combination of these strategies. To reduce speed on the roads, for example, it would probably be necessary to lower speed limits limits of 30 km per hour in urban areas, 80 on rural roads and 100 on motorways have been proposed , improve po lice enforcement, use speed cameras widely and employ speed reducing road construction such as roundabouts and traffic calming measures. A narrow approach that aims solely at reducing the accident rates sometimes to the detriment of air and noise quality, for example needs to change to the pursuit of strategies that also benefit the envi ronment, improve the quality of life and give greater overall health benefits . Increasing the safety of vulnerable road users in cluding cyclists, pedestrians, children and very old people should be a priority. Measures should be taken to ensure that accident risk is no longer a de terrent to cycling and walking by, for example, im proving infrastructures and creating conditions for safer cycling. The burden of traffic deaths and injuries can prob ably be significantly reduced only if the amount of road traffic is reduced. This can be achieved through both push measures designed to deter motor ve hicle use such as restricting the numbers of park ing spaces and pull measures designed to make other modes more attractive such as establishing pedestrian areas to increase the safety of walking, and improving rail and public transport services and peoples access to them . The nature of and need for mobility, the structure of the transport sector and patterns of road and land use need radical rethinking. Policies in keeping with such an approach are more likely to emerge as vi able options in costbenefit terms if health effects are valued appropriately and the full range of health implications that is, pollution and noise as well as accidents are also taken into account. Serious health effects occur at levels of exposure to air pollutants that are common in European coun tries. Short term increases in respirable particulate mat ter particles that are less than 10 millionths of a metre m across and small enough to get into the lungs PM 10 lead to increased mortality, increased admissions to hospital for respiratory and cardio vascular diseases, increased frequency of respiratory symptoms and use of medication by people with asthma, and reduced lung function . In addi tion to these acute effects, evidence shows that re current cumulative exposure increases morbidity and reduces life expectancy; follow up studies have found that particulate matter is associated with higher long term mortality , increases in respiratory dis eases and reduced lung function. Particulate matter itself is a mix of organic and in organic substances. It is not clear whether its health effects are linked to one or more of these substances, or to the number, surface area or mass of the parti cles particle mass concentration is the indicator used in many epidemiological studies, in guidelines and standards . Growing evidence indicates that smaller respirable particulate matter less than 2.5 m PM 2.5 may be more relevant to health than the larger PM 10 . More recently, ultra fine particles below 0.1 m have been associated with stronger effects on lung function and symptoms in asthmatics than ei ther PM 10 or PM 2.5 . The association of particulate matter with health effects has been determined in environments with complex mixtures of highly correlated pollutants, making it difficult to disentangle individual effects. The effects attributed to particulate matter could therefore be interpreted as indicating the effects of the pollutant mixture as a whole. The evidence on the health effects of sulfur, and nitrogen dioxide NO 2 and other pollutants resulting directly from the combustion of fossil fuels is similarly unclear. The effects may actually represent the impact of fine particles that are not usually monitored. The esti mates of health impact for each pollutant should therefore take account on the complexity of the situ ation. Ozone O 3 has been independently associated with reductions in lung function, increased bronchial reactivity and admissions to hospital. It has also been associated with day to day variations in mortality in studies in Europe, though not in North America. This might be explained by the more common use of air conditioning, normally accompanied by closed windows, in North America. Recent studies have also suggested an independent effect from low levels of carbon monoxide CO on admissions to hospital for and mortality from car diovascular diseases . The negative impact of lead on neurocognitive func tion in children is well demonstrated and, in coun tries where leaded petrol is still used, it is an important source of exposure see Chapter 4 . While traffic related air pollution contributes most to morbidity and mortality from cardiovascular and respiratory diseases, several components of diesel and petrol engine exhausts are known to cause cancer in animals and there is evidence of an association between exposure to diesel and cancer in human beings. A recent analysis of many studies showed a 40 increase in lung cancer risk for long term, high level occupational exposure to diesel. On that basis, the California Environmental Protection Agency adopted, in August 1998, the legal definition of toxic air contaminant for particles emitted from diesel engines . Two large longitudinal studies of exposure to ambient air pollutants found an in crease in the risk of developing lung cancer for the general population, of a similar magnitude to the risk for cardiopulmonary diseases. Smoking and oc cupational exposure may make this effect more pow erful. In addition, some evidence suggests an increased risk of childhood leukaemia from exposure to vehicle exhaust, where benzene may be the responsible agent. In view of the higher background incidence rate of lung cancer, the impact of engine exhaust particularly diesel exposure on the population is likely to be much greater for lung cancer than for leukaemia, especially after factoring in occupational exposures. The present evidence of cancer risks justifies the precaution of avoiding any increase in exposure to suspected carcinogens. The anticipated health effects of climate change in duced by air pollution, notably carbon dioxide CO 2 , include direct effects such as deaths related to heat waves, floods and droughts. Other effects will result from disturbances to complex physical and ecological processes, such as changes in the amount and quality of water and in the patterns of infectious diseases. Some of the health effects will become evident within a decade and others will take longer to appear. Motor vehicle traffic is the main source of ground level urban concentrations of air pollutants with recognized hazardous properties. In northern Europe it contributes practically all CO, 75 of nitrogen oxides NO x , and about 40 of the PM 10 concentrations. Traffic contributes disproportion ately to human exposure to air pollutants, as these pollutants are emitted near nose height and in close proximity to people. One quarter of the CO 2 emissions in EU countries comes from traffic, and the contribution of traffic fumes to the formation of tropospheric O 3 is sub stantial and expected to increase. The predicted health consequences of climatic change can there fore be directly linked to road traffic in Europe, al though they will be experienced around the world. Data collected from systems monitoring urban am bient pollutants in the WHO European Region over the last decade show that: levels of particulate matter have decreased in most cities, but increased in some very polluted cities in central and eastern Europe Fig. 5 ; NO 2 and O 3 levels have not changed; and sulfur dioxide SO 2 levels have decreased substan tially. These data have some limitations, especially with respect to the monitoring of particulate matter. An assessment of the environment in the EU re ports that emissions in countries have been declin ing overall, but those from transport, such as NO x , are increasing, as growth in the number of cars off sets the benefits from technical improvements . Effective strategies for emission reductions and de clines in industrial activity have resulted in impor tant reductions in SO 2 and lead over the last decade. Improving urban air quality and reducing tropo spheric O 3 now pose the main challenges, and will require important shifts from business as usual scenarios. A substantial proportion of the human exposure to air pollution generated by road traffic occurs in ur ban areas, where most of the European population lives; people are exposed indoors, inside cars or on the roadside. People spend most of their time in doors, but outdoor air pollution is the main deter minant of indoor air quality except in homes where people smoke . CO and particulate matter enter indoors quite freely, while O 3 reaches relevant con centrations indoors only when windows are opened. Levels of CO and benzene inside cars are around 2 5 times higher than at the roadside, and car users are exposed to more pollutants than pedestrians, cyclists or users of public transport sharing the same road . The levels and composition of pollutants in the air depend not only on the number of vehicles but also on their age, engine type and condition, and the type of fuels used, as well as on meteorology, the shape of the urban environment and the way traffic is organized. While much is being done to improve the technology, a few issues relevant to health also need attention. Heavy vehicles are major polluters. For example, when compared to a car with a catalytic converter, a diesel truck produces 50100 times more fine and ultra fine particles per km travelled. Modern diesel engines may emit less PM 2.5 but a larger number of ultra fine particles than older engines. If ultra fine particles or the number of particles, rather than par ticle mass, are the cause of health effects, as now suspected, the new diesels cause more harm than the old ones. The contribution of mopeds with two stroke en gines to air pollution and related health impacts is not known, although there are indications that they produce several times more CO and hydrocarbons than cars with catalytic converters. Mopeds are used to make a large proportion of urban trips in south ern Europe, and many have such engines. In addition, the flow of old cars into eastern Eu rope in the 1990s has been associated with increases in particulate matter in large cities. Exposureresponse relationships from epidemiologi cal studies and data from ambient air monitoring specific for the population of interest can be used to estimate the health effects of air pollutants. There is much uncertainty about these estimates, and re sults depend on such factors as: whether the estimates of dose and response come from studies of daily variation in mortality or of long term impacts estimates in the latter are 36 times higher ; which level of particulate matter exposure is de fined as the baseline over which an added burden will be calculated; and whether estimates are made for the whole popu lation or only for the subgroup similar in age and gender, for example to participants of the exposureresponse studies. Nevertheless, using the best available information and making adjustments for potential sources of error, good, cautious indications can be derived of the magnitude of the burden of disease associated with air pollutants for a given population. For example, about 36 000129 000 adult deaths a year can be attributed to long term exposure to air pollution generated by traffic in European cities. This assumes that around 35 of the deaths attrib uted to particulate matter pollution are due to traf fic air pollution a conservative estimate of the fraction of particulate matter coming from traffic in urban areas . The estimated annual number of deaths in the WHO European Region attributed to total air pollution is 102 000368 000 . This is based on applying a conservative estimate of expo sureresponse found in the follow up studies of adults in the United States to estimates of particulate matter exposure in European cities. The same analy sis also estimates that particulate matter accounts for 600010 000 additional admissions to hospital for respiratory diseases in European cities every year. An application of the same United States exposure response results to the population of the Nether lands, whose circumstances are comparable to those of the original studies, concluded that an increase of 10 g m 3 PM 2.5 would reduce life expectancy by over one year . When the results were applied to the United States population, it was concluded that the levels of variation in air pollution observed in the studies 1030 g m 3 could conceivably be associated with a change in life expectancy of the order of several years . A recent estimate of the health effects of air pollut ants from traffic in Austria, France and Switzerland and their related costs, using comparable methods, found that air pollution caused 6 of total mortal ity in the three countries, or over 40 000 deaths per year . About half of all mortality caused by air pollution was attributed to motorized traffic. This corresponds to about twice the number of deaths due to traffic accidents in these countries. In addi tion, traffic related air pollution accounted for: more than 25 000 new cases of chronic bronchitis in adults, more than 290 000 episodes of bronchitis in children, more than 500 000 asthma attacks and more than 16 million person days of restricted ac tivity . A number of studies have recently shown an asso ciation between respiratory disease and proximity to roads that are busy and those travelled by a high number of heavy vehicles or trucks . Children living near roads with heavy vehicle traffic are at greater risk of respiratory disease. Most studies sug gest an increased risk of around 50 . These studies may have captured the effects of actual mixtures of pollutants and they strengthen the case for traffic generated air pollutants affecting health. The magnitude and seriousness of the health effects of air pollution, a significant part of which can be attributed to traffic, call for further reductions in traffic related emissions of air pollution. Technological improvements, such as the introduc tion of unleaded petrol and catalytic converters, have already had a positive impact. In moving forward, however, a holistic approach should be adopted. Fo cusing efforts on reducing one pollutant may be ineffective, since the effect associated with that pol lutant may well be a proxy for the effect of the pol lutant mix, and this mix should be addressed. Tackling individual pollutants in isolation could even be counterproductive if it leads to increases in another pollutant component. Attempting to lower CO 2 emissions through the promotion of so called new diesel vehicles, for example, would lead to an increased number of ultra fine particles, which seem themselves to be a cause of concern. Similarly, in selecting actions to reduce emissions of greenhouse gases, those that also reduce other air pollutants, such as particulate matter, should have priority. The effect on the pollution mix as a whole must always be considered in designing interventions. Even the best designed technological responses to the reduction of emissions from vehicles may not be enough to compensate for traffic volume, which is increasing throughout Europe. Controlling the growth in traffic, especially in urban areas, will be essential if further traffic induced harm to the health of European populations is to be avoided. It has not been possible to identify a threshold for PM 10 below which no health effects are observed. Indeed, serious health effects occur at pollutant con centrations that are well below existing air quality guidelines and standards. WHO argues for lower ing these in the case of O 3 and particulate matter, and some national and international bodies have done so. WHO does not give a guideline level for PM 10 , but provides information about the additional risk of adverse health effects associated with in creased levels. Research needs to move forward on a number of fronts: the components and sources of particulate pollution including the effect of ultra fine parti cles ; the link between traffic volumes mixes and health effects such as childhood respiratory disease and cancer; the effects of air pollution exposure within cars and while bicycling and walking; the carcinogenic effects of diesel and petrol in populations; and the identification of cost effective technological and economic strategies for respond ing to the problem of transport generated air pollu tion. Wellbeing is an integral part of the WHO defini tion of health, which makes clear that good health is more than the absence of physical health burdens and includes such things as having social support, being free of threats of violence, not being anxious or fearful, being in a good temper and feeling em powered . The psychological and physical as pects of wellbeing are difficult to disentangle: physical damage provokes mental responses pain, anguish, distress and psychological disturbances can lead to physical ill health. Much of the discussion of health consequences in earlier chapters already touches to some extent on the psychological. This chapter draws attention to some of the elements that have not yet been specifically addressed. One well known mental effect from transport is that caused by lead emissions from petrol on the cogni tive development of children. The neurotoxic ef fects of lead have been known for a long time, but research in the 1980s and early 1990s demonstrated neurobehavioural effects at much lower exposure levels than before: levels often prevalent in the envi ronment . Recent prospective studies have re lated deficits in neurobehavioral function in children to blood lead concentrations as low as 0.5 mol litre 100 g litre . Most of the early studies on developmental lead neurotoxicity described the adverse effects in terms of IQ results . More recent studies suggest that lead affects several specific brain functions, particu larly attention, motor coordination, visuospatial function and language. Some follow up studies of teenagers have shown cognitive dysfunction to be long lasting, affecting functional abilities and aca demic progress . Children are particularly vulnerable. They not only have greater intakes of lead than adults 35 times higher, when adjustments are made for differences in weight but also absorb and retain greater amounts of the lead to which they are exposed. Their higher sensitivity is reflected in the fact that the lowest level at which adverse effects are observed in adults is es timated to be 40 g dl; that for children is 10 g dl. In western countries of the European Region, effec tive laws on the level of lead in petrol control some of the problem posed by lead emissions. The prob lem remains, however, in eastern countries. The number of motor vehicle accidents and the physical injuries and deaths resulting from them are closely monitored in most countries. This is not true of the long term psychological effects commonly experienced by survivors of motor vehicle accidents, even when they have minimal or no physical injury. Studies have found that 14 of survivors have di agnosable posttraumatic stress disorder and 25 have psychiatric problems one year after an accident, and one third have clinically significant symptoms at follow up 18 months after an accident . Posttraumatic stress disorder is a debilitating condition that involves such symptoms as: re experiencing the trauma through nightmares, flashbacks or uncontrollable, intrusive recollec tions; adopting avoidance techniques including keep ing away from situations that trigger recollections of the event, blocking feelings and becoming de tached and estranged from others; and excessive arousal resulting in sleep difficulties, poor concentration and memory, and being hyperalert and easily startled . Governments and funding agencies neglect the dis order, and it is rarely taken into account in assess ments of the health costs of traffic accidents. A study in the United Kingdom found that one in three children involved in road traffic accidents suf fered from posttraumatic stress disorder when in terviewed 22 and 79 days afterwards, while only 3 of children from the general population studied in a similar way were found to have the disorder . Neither the type of the accident nor the nature and severity of the physical injuries were related to the development of the disorder; the childs perception of the accident as life threatening was the most im portant determinant. The study found that the psy chological needs of the children involved remained unrecognized, and none had received any profes sional help. As documented in Chapter 1, traffic noise has been shown to induce nervousness, depression, sleepless ness and undue irritability, but other aspects of trans port also cause irritation and frustration. Regular exposure to traffic congestion impairs health, psy chological adjustment, work performance and over all satisfaction with life . Congestion constrains movement, which increases blood pressure and frus tration tolerance. This phenomenon not only re duces the wellbeing of those experiencing it but can also lead to aggressive behaviour and increased like lihood of involvement in a crash . Aggressive behaviour on the road is common and appears to be increasing. Marsh Collett found that 25 of young drivers aged 1725 would chase another driver if they had been offended, and Joint reported that 60 of study participants behaved aggressively while driving. The car has been described as an instrument of dominance, with the road as an arena for competition and control. The car also symbolizes power and provides some pro tection, which makes drivers less restrained . Excessive automobile use has affected peoples so cial lives. The car has enabled them to move away from cities and to settle in suburban areas. Many of these areas have been developed around the car, however, and without considering peoples psycho logical needs. Close knit communities have given way to neighbourhoods that do not encourage so cial interaction, and this has resulted in increased social isolation . These new areas very rarely include local schools, small stores or other places where people could interact. Instead, shopping amenities have moved to large, impersonal out of town centres. In addition, the growth in the use of the car has affected social contact through the so called com munity severance effect: the divisive effects of a road on those in the locality. A seminal study of the im pact of traffic on three streets in an area of San Fran cisco illustrates how traffic volumes and speed influence the way people use streets for non traffic functions . Three streets were studied, similar in all aspects except traffic volume: 2000 vehicles per day in one street referred to as Light Street , 8000 in another Moderate Street , and 16 000 in the third Heavy Street . Residents were asked about their perceptions of their neighbourhood. The study observed a variety of behaviour, including pedes trian delay times; numbers of closed windows, drawn blinds, parked cars and flower boxes; and amount of litter. Those living on Light Street had three times as many friends and twice as many acquaintances among their neighbours as those living on Heavy Street Table 3 . Light Street was perceived to be friendly, and families with children felt relatively free from traf fic dangers. In contrast, Heavy Street had little or no pavement activity and was used solely as a cor ridor between the sanctuary of individual homes and the outside world . The decline of environmen tal quality on Heavy Street had led to a process of environmental selection and adaptation in the streets residential make up, which had changed sig nificantly over the years as a result of the hostile traffic environment. Residents kept very much to themselves and had withdrawn from the street en vironment. There was little sense of community . Measures that reduce the severance effects of motor traffic are important because of the protective ef fect on health of social support networks, which work either directly by promoting health or by buff ering the adverse effect of stressors. Low levels of social support have been linked to increased mor tality rates from all causes: people with few social contacts may be at more than twice the risk of those with many contacts. Good social support networks appear to be most important for vulnerable groups such as elderly people and children. Evidence indi cates that lack of social support can increase mor tality from coronary heart disease by up to four times . High traffic density affects childrens development. Fewer and fewer children are being allowed to walk or cycle even short distances, because parents are worried about accidents Fig. 6 . Indeed, several studies point out that the space within which chil dren can move freely shrinks significantly as street traffic increases in the immediate environment . Children have become more dependent and less physically active, while parents have less time to spare. This reduction in levels of physical activity not only has longer term effects on physical wellbe ing as documented in Chapter 5 but can also af fect childrens stamina, alertness at school and academic performance. Further, these conditions withhold an important kind of experience from children, hindering their personal development, as well as limiting their con tact with their peers. A study by Httenmoser investigated two contrasting groups of 5 year olds. The children in group A were raised in surround ings permitting them to play both unhindered by street traffic and without the presence of adults. Children in group B could not leave their homes unaccompanied by adults. The study found a clear connection between the time that children spent outside and the dangerousness and perceived attrac tiveness of their living environments. When chil dren in group B played in their neighbourhood, adults accompanied them and the time they spent outside was considerably shorter, since adults were not prepared to supervise for more than 12 hours. Social contact with other children in the immedi ate neighbourhood was half of that of the children in group A. The same was true for the adults . Httenmoser showed that unsuitable living surroundings considerably hinder childrens social and motor development and put a heavy strain on parents. Deficient motor skills often have social and psychological consequences, such as difficulties in teracting with other children and coping with street traffic. The use of lower traffic speeds on main streets and walking speeds in residential areas appears to be of decisive importance for the development of children. Where lower speeds are engineered through traffic calming, evidence suggests some perceived improve ments in quality of life or livability, including im proved safety for pedestrians and cyclists, benefits for families with children, and greater independent mobility for children, especially for those aged 79. Chapter 5 illustrates how a switch to physically ac tive modes of transport can make a significant dif ference to physical wellbeing. The psychological benefits of such a shift have also been documented. Research shows that people who are physically ac tive or have higher levels of cardiorespiratory fit ness have better moods, higher self esteem and better cognitive functioning than those who are physically less fit. A survey of about 4000 respondents across Canada found that people who reported higher levels of total daily leisure time energy expenditure had more positive moods. The authors also found an inverse relationship between physical activity and symptoms of depression, even at moderate exercise levels. A cross sectional study made secondary ana lyses of two surveys in Canada and two in the United States, conducted between 1971 and 1981 ; it associated physical activity with fewer symptoms of anxiety and depression and with better moods and general wellbeing. These associations were strong est among women and among people aged 40 and over. Much remains to be discovered about the nature, significance and prevalence of the psychological ef fects of transport. This might help to explain why there has been so little monitoring of these effects. Nevertheless, beginning to develop a better data base of relevant psychological outcomes is the only way to begin to understand how widespread and serious the problems are and what kind of ap proaches to ameliorating them are likely to be most successful. Ignoring the psychological effects of transport prob ably leads to significantly underestimating the det rimental health effects of motorized transport. This is particularly serious because many of the psycho logical effects have the important characteristic of being external: that is, effects imposed on others and not considered by those generating them. This ex ternality provides much of the justification for gov ernment involvement. Psychosocial variables should become an integral part of impact assessments. This can only happen once appropriate indicators have been identified and methods developed to measure and analyse them. Collaboration with those already involved in carry ing out social impact assessments will be crucial. Neither a comprehensive or detailed picture of the problem of the psychological effects of traffic nor a well developed menu of strategies to deal with them is available. Societies are more likely to be moving in the right direction, however, if they pursue a vi sion of people friendly, liveable environments. Choosing to walk or cycle for ones daily transport needs offers two important kinds of benefits. The first, discussed in earlier chapters, includes those associated with the reduced use of motorized trans port noise, air pollution and accident rates would all fall. The second is the benefits to health from regular physical exercise. These are likely to be very substantial but have been largely overlooked. If ad equately accounted for, they could completely change the costbenefit ratios of transport policy decisions. Convincing scientific evidence now shows the sub stantial health benefits of physical activity . In 1996, the US Surgeon General produced a com prehensive report on these health benefits , simi lar to the 1964 report on the negative effects of to bacco. This is both a tribute to the credibility of the evidence and a reflection of the significance attached to the findings. It is hoped that a concerted response to the physical activity report is less slow than was the case with smoking. Walking and cycling to work have been shown to meet metabolic criteria for achieving health ben efits from exercise . The health benefits of regu lar sustained physical activity include : a 50 reduction in the risk of developing coro nary heart disease a similar effect to not smok ing ; a 50 reduction in the risk of developing adult diabetes; a 50 reduction in the risk of becoming obese; a 30 reduction in the risk of developing hyper tension; a 10 8 mmHg decline in blood pressure in peo ple with hypertension a similar effect to drugs ; reduced osteoporosis; relief of symptoms of depression and anxiety; and prevention of falls in the elderly. Health risks are associated with cycling and walk ing, too, the most serious of which are accidents involving cars. Nevertheless, preliminary analysis in the United Kingdom shows that on balance the ben efits to life expectancy of choosing to cycle are 20 times the injury risks incurred by that choice . Further evidence in different settings is required. A total of 30 minutes of brisk walking or cycling a day, on most days, even if carried out in ten to fifteen minute episodes, reduces the risk of deve loping cardiovascular diseases, diabetes and hyper tension, and helps to control blood lipids and body weight . This evidence is mostly from studies in middle aged, white males, but the few studies in women, young people and the elderly point in the same direction. This is new evidence and especially useful for pub lic health, as it was previously thought that only vig orous, uninterrupted exercise, such as jogging, could provide such benefits . While the benefits of physical activity increase with the intensity and fre quency of exercise, the greatest come when people who have been sedentary or minimally active en gage in moderate activity. In addition, moderate physical activity is a more realistic goal for most people and carries a lower risk of cardiovascular or orthopaedic complications than vigorous activity. It is therefore safer to recommend for the general population. The number of cycling and walking trips in Europe remains small. On average 5 of all trips in EU countries were made by bicycle in 1995 . Cy cling habits vary widely. Cycling is much more com mon in northern countries; in Denmark and the Netherlands, for example, people make 18 and 27 of trips, respectively, by bicycle, and cycle on average 850 km per year. In Mediterranean coun tries, by contrast, only 14 of trips are made by bicycle and average annual cycling distances are 2070 km. Daily cycling trips among adults in six European countries with more detailed information range from about 1 in the Netherlands to as low as 0.1 in the United Kingdom . Although these are the coun tries in Europe with the most cycling and walking, cars are used to make 3065 of short trips under 5 km . In Europe the average trip taken on foot to reach work or for leisure or shopping is currently about 2 km and the average cycling trip is about 35 km . Each takes around 15 minutes, enough to pro vide the above mentioned health benefits. Walking is declining as a means of transport. In the United Kingdom, miles walked fell 20 between the early 1970s and the early 1990s; the decline was larger among children . In Finland during the same period, the number of trips on foot dropped from 25 to around 10 and cycling trips from 12 to 7 , while trips by car increased from 45 to 70 . Half of the adult population in the western world is sedentary or minimally active, and levels of physi cal activity are declining. Obesity is increasing in western countries in spite of a decrease in calorie intake, and this is mostly due to increasingly seden tary lifestyles. Physical inactivity is now more preva lent than tobacco smoking, and together these risk factors account for the greatest number of deaths and years of life lost in developed countries . In Finland it was estimated that a 37 reduction in deaths from coronary heart disease could be ex pected if another 8 of the working population chose to walk or cycle to work . The Finnish transport ministry estimated that savings worth about US ,80235 million a year would result from the doubling of cycling distances travelled . Policies favouring walking and cycling in York, United Kingdom led to a 40 reduction in road casualties compared with a 1.5 reduction in the country for the same period . Cycling and walking are forms of physical exercise accessible to the vast majority of the population, regardless of income, age and location: it is estimated that over 96 of citizens can walk, and over 75 can ride a bicycle . The public health efforts to increase physical activ ity have so far focused largely on education and skill development in individuals, and on physical activ ity as leisure. Rarely have they considered environ mental determinants of peoples choice of and ability to maintain regular physical activity, and built on these to design interventions to promote physical activity. Factors such as the availability of public transport, high housing density and street connec tivity have all been shown to be associated with higher levels of physical activity. In addition, evi dence shows that people are more likely to take up activities that are easy of access, take place in a pleas ant and safe environment for example, in clean air and green areas , fit easily into the daily schedule and have reasonable cost. Fear of accidents and street violence and the barrier effect created by congested roads and the priority given to cars deter people from cycling and walking. Policies promoting a shift towards more walking and cycling as transport modes should concentrate on the trips for which motorized modes are often used but whose length easily permits their completion on foot or by bicycle; this applies to many trips shorter than 5 km zone B in Fig. 7 . For policy makers the barriers to promoting cycling and walking have mostly derived from a lack of ap preciation of the extent of benefits involved. This is reflected in the absence of these effects from impact assessments and economic valuations of transport policies . The health sector needs to ensure that scientific evidence on health implications is made available in a way that facilitates costbenefit analy ses and policy decisions. It should reanalyse avail able data sets to respond to questions concerning, for example, the balance between the health ben efits on noncommunicable diseases and costs in injuries and deaths of promoting active transport. Methods for the economic valuation of these health effects should be adapted and made widely avail able, and effects and related costs should be docu mented for locations across the European Region. Data collection on cycling and walking across Europe is not systematic or standardized. Report ing is irregular, with different definitions and range of values. The monitoring of physically active modes of transport should be improved. Public and non motorized transport offer opportu nities for regular physical activity, integrated into daily life at minimal cost, for large segments of the population. Modal shifts to physically active trans port are likely to bring major benefits to public health, the environment and quality of life, and to decrease congestion. Strategies designed to engineer such shifts should be energetically pursued, espe cially in urban and suburban areas, and their effects monitored and evaluated. The health effects of transport fall disproportion ately heavily on certain groups of the population. The areas they live, work or travel in may have traf fic of higher volumes or speeds, or specific geo graphical, topographical or settlement characteristics that intensify levels of air pollutants and noise, and increase the risk of accidents. Owing to their age, illness or disability, some people are more sensitive to any given traffic risk. Others use modes of trans port associated with greater risks, such as motorcy cles. Many of the health risks from transport accumulate in the same communities, often those that already have the worst socioeconomic and health status. Most of the European population 70 lives, works, and spends most of its travel time in towns and cities. Not surprisingly, much of the health impact from road transport is experienced in these urban environments. Most injuries to pedestrians and cyclists occur in urban areas , as do cases of pollution induced illness and noise annoyance. Across Europe, the health impact of transport is concentrated in inner city districts and along busy roads areas where traffic density is particularly high and many people live and work. The result is in creased risk of injury for pedestrians and cyclists, exacerbation of the severance effect of traffic, and noise and air pollution levels that are higher than in suburban, peri urban and rural areas . Analysis of air pollution data in England, for example, has shown that many central districts in cities, especially in London, record levels of NO 2 that exceed the maximum limits agreed by the government. Several recent studies have reported that children living near busy roads or roads with heavy diesel vehicle traffic are exposed to particularly high levels of particulate matter and have a higher incidence of respiratory symptoms , increased hospital admissions for asthma and a higher prevalence of wheezing and allergic rhinitis . Nevertheless, transport also affects health in rural areas. Communities living in rural alpine valleys, for example, have been shown to be exposed to high local concentrations of traffic related air pollution and noise . Given the low level of exposure rela tive to urban environments, rural areas suffer a dis proportionate number of road traffic fatalities, probably owing to the higher vehicle speeds . The burden of transport induced ill health borne by the poor has been most closely studied in rela tion to risks of traffic injury. Pedestrian casualties in Scotland, for example, are disproportionately drawn from the poorer socioeconomic groups . In Europe more generally, road traffic casualties are known to be higher among manual workers and their children and the unemployed than in profes sionals . The results of studies on children most clearly illus trate the association between social deprivation and road casualty rates. Children living in deprived areas have high casualty rates and these have a dose response relationship with the degree of deprivation . In the United Kingdom, the pedestrian death rate for unskilled workers children is over four times that of professionals children. The extent to which living in a more hazardous en vironment explains the higher accident rates ob served in lower socioeconomic groups is not clear. Traffic volumes and the proportion of vehicles ex ceeding speed limits are higher in poorer than in more affluent areas . Car ownership appears to explain some of the association between social class and injuries. Certainly children from families without cars have been observed to cross greater numbers of roads than those from car owning house holds , and are therefore more exposed to the risk of accidents. The picture with respect to exercise is not as clear. Although the poor are less likely to own cars and travel by car, there are few data to show how this influences levels of exercise. Data suggest that poorer groups are less physically active in general, but what role transport related exercise plays in this is not certain. As mentioned, poorer groups in Europe also appear to suffer more than affluent groups from air pollu tion. The reason is probably the environments in which they live and work, even though poorer peo ple are less likely to drive and motor vehicle occu pants are often exposed to higher levels of air pollution than cyclists and walkers . Car oc cupants are likely to spend significantly less time in polluting traffic than the poor spend exposed to emissions from busy roads in their localities. In addition, good evidence shows both that the poor are less healthy and that ill people particularly those with respiratory and coronary illnesses are more vulnerable to the effects of air pollution . For example, some studies show children with pre existing respiratory disease with more reduced lung function than healthy children in reaction to air pol lution episodes . Further, the poorer health of the economically disadvantaged may be worsened by the relative inaccessibility to them of services such as large supermarkets and shopping centres with their cheaper and healthier foods and health care facilities. With urban sprawl, services and ameni ties have moved to outskirts of cities, and are only readily reached by car. The poor are often exposed to elevated noise levels from traffic, to which some limited and indirect evidence interestingly suggests they may have re duced sensitivity. Spanish research suggests that bet ter educated people who usually live and work in areas with relatively low noise levels are more sen sitive to traffic noise than those with poorer educa tion . Perhaps poor people living in areas with high traffic volumes become accustomed to the gradually increasing noise levels. Certainly research has found that people experiencing gradual increases are less irritated than those confronted with a step change in noise levels . The noise levels to which people become accustomed, however, are not good for their mental or physical health. As men tioned in Chapter 1, some of the adaptation strat egies lead to elevated stress hormone levels and blood pressure. To some extent, residence can explain the relation ship between transport related health effects and socioeconomic status described in this section. The poor often live in inner city areas with particularly high exposure to accidents and noise and air pollu tion. In fact this may be one reason why they are clustered in these areas; the high noise and air pol lution levels and disturbance from traffic are likely to drive real estate values down and the more afflu ent out. In Norway, for example, people with higher incomes are significantly less disturbed by road traf fic noise than those who earn less. The former use their income to buy homes in better environments and thereby avoid such disturbance . Women are disproportionately represented among the poorer socioeconomic groups. They are also less likely than men to be car occupants are and more likely to walk; the number of trips on foot is higher for women than for men across OECD countries . Interestingly, however, women in Europe are in gen eral less likely than men to be injured or killed as pedestrians. Research in the United Kingdom has linked this partly with women walking more often than men on familiar roads within about 1 km of their homes; the study has also found, however, that older female pedestrians have two and a half times the risk of injury of males of the same age for the same distance walked or number of roads crossed . Nevertheless, research suggests that in gen eral males take more risks than females in the traffic environment, as has been found among children , cyclists and car drivers . Poor women in inner cities do not have good access to services such as hospitals and supermarkets. Even public transport does not always serve women well. It is usually geared to the needs of workers, and thus the scheduling of the most frequent services does not always suit women with young children. Children are a particularly vulnerable group. In many European countries, traffic related injuries are the most common single cause of hospital admis sion among those aged 515 years. Most of these casualties take place on urban streets. In 1990 pe destrian and cyclist fatalities were the single largest cause of death in children aged 014 in OECD countries . One in every three road traffic deaths involves a person younger than 25 years . As mentioned in Chapter 4, the barriers to physical activity created by heavy traffic are especially restric tive for children. Children are becoming habituated to a sedentary lifestyle . This is particularly alarming in view of the evidence that cardiovascu lar risk factors including obesity tend to track from childhood to adulthood. Establishing good physi cal activity patterns in childhood is a key to reduc ing cardiovascular diseases . Elderly people comprise an important and growing group in society with multiple sensitivities to the negative health effects of transport. They show a gradual decrease in their abilities to cope with diffi cult traffic. Traffic regulation and infrastructure de sign make little allowance for this; pedestrian lights, for example, allow insufficient time for elderly peo ple comfortably to cross roads. Moreover, most peo ple with hearing difficulties are elderly, and traffic noise can compound their communication problems and hence reduce their readiness to make contacts and interact socially. Aware of their difficulties, most elderly people tend to disengage from traffic and become less mobile. The perceived dangers and threats of traffic can lead to insecurity, anxiety and stress, and thus to social isolation, distrust of others and reduction in social and neighbourhood networks of support , as well as the loss of important opportunities for regular physical activity. Despite this self restriction and even though peo ple over 65 years make up less than 15 of the popu lation, the elderly comprise roughly half of the pedestrians killed in Europe each year . Hillman estimates the fatality rate for younger pensioners per kilometre walked to be about twice as high as that among children and the rate for older pensioners, about ten times as high. In addition, the elderly have been found to be most at risk of pollution related premature death in time series studies of mortality, possibly because of the high rates of illness among this group. The United Kingdom Department of Health has estimated that periods of high air pollution in Great Britain may hasten by a few days or weeks up to 24 100 deaths each year, mainly among older people and the sick, and 23 900 hospital admissions, as well as causing additional admissions. Pedestrians and cyclists stand out as particularly vulnerable road users. Not only is the severity of accidents among pedestrians almost twice as high as that in car occupants, but cyclists and pedestri ans are disproportionately involved in crashes, given both the amount of time they spend on the road and the relatively short distances they travel . Pedestrians and cyclists account for 45 of all road deaths in the United Kingdom and over 50 in Hungary. The proportion is substantially lower in western European countries: 17 in France, 20 in Germany and around 30 in Denmark and the Netherlands where cycling occupies a much higher modal share of journeys than, for example, in the United Kingdom. In both absolute numbers and as a proportion of all road deaths, annual deaths of pedestrians and cy clists have fallen in most European countries where data are available. Notable exceptions, however, in clude the increased number of pedestrians killed in Greece. Deaths among cyclists increased in number in the Czech Republic, eastern Germany and Hun gary, but comprise a declining proportion of all road deaths, owing to absolute increases in the numbers of deaths among car drivers and passengers. The reduced mobility of pedestrians and cyclists especially children and the elderly resulting from fear of road traffic may have helped to reduce the number of traffic casualties. To reduce the risks, el derly people living close to busy roads restrict their territorial range from home, and parents are increas ingly restricting their childrens independent mo bility , reducing physical activity and opportunities for unsupervised interaction with other children see Chapter 4 . Damage to social and personal development, including alertness at school and academic performance, has been docu mented. Although transport associated health risks have clear geographic patterns, these can change with demo graphic movements, and restricting attention to this dimension is simplistic in any case. To be useful, the definition of risk has to encompass income, age, illness and disability, and mode of transport used. As with health in general , the negative health effects of travel fall disproportionately on poorer socioeconomic groups, women, children and older people, which are precisely the groups least likely to benefit from the transport system, which limits their access to services, cheaper foods and other goods. A package of measures is needed to protect those at higher risk from the health effects of traffic. First and foremost, a more precise picture is needed of these effects; monitoring mechanisms need to be established and appropriate indicators of social class as well as geographic features, for example identi fied and measured. A good monitoring system iden tifies areas where action is needed and permits the evaluation of the effectiveness of the action taken. Action to assist most risk groups has to be well thought through and consider the wider picture. For example, much of the higher impact of transport on the poor is linked with where the poor live. Im proving traffic in those areas could well drive real estate prices up and drive residents out. Plans to protect the poor should incorporate traffic concerns with housing and access dimensions. Previous chapters have described the extent and nature of the health consequences of transport. The results are alarming, and public health specialists would probably seek whatever means are necessary to eliminate this unacceptable health burden. Lob byists for cars or roads, on the other hand, would argue that transport has many very substantial ben efits that significantly outweigh the costs, that the health burden is the price societies must pay for the mobility and convenience they enjoy. The framework used by economists is helpful in considering these competing points of view. Econo mists would argue that society is unlikely to be will ing to make the huge sacrifice required totally to eliminate the health burden associated with trans port. They would also point out that the transport sector has important characteristics that mean that an inadequately regulated market will fail to deliver the socially optimal pattern and level of transport. In particular, the people involved in motorized trans port do not fully bear all its costs. The external costs of transport those borne by others are known to be substantial; Table 4 summarizes those for the EU, Norway and Switzerland . No important ex ternal benefits have been identified. The existence of external costs means that, with no intervention, levels of road use will be higher than is socially optimal because the costs to society ex ceed the costs to the individual road user. Most gov ernments have recognized this point, but failed to act accordingly. As a result, although the benefits from road transport are large, they could be further increased if certain journeys were made by different means or not made at all. Taking account of health in transport decisions does not mean that health should dominate over other concerns. The many advantages of mobility and easy access to goods and services are clear. Nevertheless, governments should actively implement policies re quiring those who generate transport costs to pay for them. Ideally this would be achieved by taxing transport at a rate equal to the external costs generated by the individual road user. This would give people an in centive to reduce socially wasteful journeys; the costs are then said to be internalized. Unfortunately, such an approach is rarely practi cable, since the marginal damage done by different road users depends intimately on the context in which the journey is made and the vehicle used. The approach depends on the governments ability to monitor individual road users in these different con texts. In reality, the most that can usually be achieved is to tax complementary activities such as parking and subsidize substitutes such as public transport . An alternative is to use standards and command and control policies, although these risk imposing un necessarily high costs upon some individuals. Most governments have relied on the dual meas ures of vehicle excise duty and fuel duty, sup plemented by a host of standards based measures. Unfortunately, the use of fuel duty correlates with pollution problems very badly. It does not distin guish between the emission characteristics of vehi cles, or vary with location and time of day. Further, even high fuel taxes are unlikely to cause much change. The only pollution problem for which fuel taxes might be the appropriate measure is that of carbon emissions. In this case, the relationship between the amount of fuel used and the carbon emitted is con stant; location characteristics of the pollutant are not important, and no technology is capable of re moving carbon emissions from vehicle exhausts. Vehicle excise duties are an even less satisfactory approach. Once paid, they give road users no in centive to restrain the use of their vehicles. More appropriate strategies include: fuel switching through price differentials, to en courage the use of more health friendly fuels im posed through an explicit policy that creates incentives for research on so called green fuels and their introduction into the market place ; annual vehicle inspections, roadside checks and vehicle scrapping, to reduce the problem of poorly maintained and older vehicles, which have far greater emissions per distance travelled than prop erly maintained or newer cars; setting emission standards for new vehicles a widely employed approach in Europe, which has significantly reduced air pollution emission rates, although failing to provide the continuing incen tive for the development of cleaner engines that would result from taxing the purchase of vehicles according to their environmental characteristics ; and dealing with the spatial characteristics of air pol lution problems by restricting motor vehicle ac cess to certain parts of a city through, for example, cordon charging and road pricing and policies on parking and public transport. Accidents generate external costs for two main rea sons. First, there is evidence that additional road users raise the risks to other road users. Second, many countries do not charge people directly for medical treatment. As a result, individuals do not face the full cost of the accidents in which they are involved, and are likely to behave in a way that is socially sub optimal. The mandatory use of crash helmets by motorcy clists and seat belts by car occupants has reduced the costs of medical care by reducing the need for it , although some people may behave more reck lessly as a result of feeling protected. Drinkdriving laws, compulsory testing for drivers licences and speed restrictions appear to be worth while, although good evidence on their costs and effectiveness is scarce. Drinkdriving and speed con trol laws should probably be strengthened. One promising approach that has not been widely used is to make road users pay the full costs of both their own treatment and the damage they inflict on others. Individual road users differ significantly in skill, and radically increasing the damages that must be paid in the event of an accident could signifi cantly deter aberrant drivers. Insurance companies would foot the bill, but would have the incentive to raise premiums for people who are bad risks. Simi larly, requiring road users to have insurance to cover the states costs in the event of their having an acci dent would raise the cost of motoring, particularly to those who are a danger to themselves and others. Safe driving and the use and therefore production of safer cars would be financially rewarded and dangerous driving penalized in a way regulations alone could not do. Some people misjudge the risks they face; surveys show that most people think they are safer than the average driver. Taxes may be required to compen sate for this chronic underestimation of risk, and to encourage shifts to less risky modes of transport. A supplementary approach is to engage in measures intended to make people change their preferences in favour of particular forms of transport. The ex perience and knowledge of the general public and of decision makers affect their attitudes towards certain forms of transport and land use strategies. Change towards health promoting transport alter natives requires that people have access to the nec essary information and means of participation in decision making. The following are four elements of a strategy for working towards change. First, opportunities could be created for practical and positive experiences of desirable means of trans port. For example, the creation of privileged road space for safe cycling and walking in pleasant sur roundings in cities would reduce air pollutants, noise and accident risk, promote physical activity and social interaction, and benefit the environment. This could be a powerful way to form public opinion about transport options. Second, information, education and communica tion strategies could be developed to make the health and environmental implications of different trans port modes and alternative policies widely known and accessible to members of the public, including policy makers. Similarly, beneficial effects might result from policy makers and stakeholders review ing and rethinking sustainable patterns of consump tion in individual travel behaviour. Third, decisions on transport and land use projects, plans and strategies could include mechanisms to ensure wide consultation. This would prevent the domination and distortion of the decision making process by lobby groups. People need to be informed, to have the opportunity to express informed opin ions and to have these followed by appropriate ac tion. Finally, comprehensive assessments of the impact of policy options on health and the environment should be carried out and the results made widely accessible to the public. Making transport users take more responsibility for the costs of the ill health they generate for others the internalization of costs is a key strategy for tack ling transport externalities. Nevertheless, another important facet of reducing the external costs of transport is government investment on behalf of the public in reducing the total level of these costs. For example, governments have invested in noise barri ers, quieter road surfaces, research into quieter, less polluting and safer cars, roads with more safety fea tures for road users inside and outside of cars such as speed humps , cycle paths in inhabited areas and urban plans that ameliorate the negative health con sequences of associated transport systems. The lack of such investment does not result from poor re sults from costbenefit analyses. Very often the rea son is that such measures have received no active consideration, or have been considered but not prop erly evaluated. For example, investment in cycling infrastructure is currently made on the basis of time savings and the reduction of risks to existing cyclists. This ignores the fact that the creation of new infrastructure would generate additional trips. The number of extra trips might be substantial because the risks of accidents are a major part of the perceived costs of cycling. Earlier chapters have detailed the health benefits of cycling. Government departments need to add esti mates of the health benefits to current and poten tial cyclists to their appraisals of cycling lanes. While technology can and has reduced the effects of transportation on health and the environment, its use can lead to unexpected results and expecta tions of what it can deliver should be realistic. As mentioned, diesel engines with lower CO 2 emissions produce many more ultra fine particles, which are being charged with responsibility for the health ef fects of particulate matter after the development of so called new diesel . Safer brakes in cars can lead drivers to take further risks, offsetting the intended benefit. Technological investments must be balanced against other types of preventive measures. Some of the effects of transport activities need fur ther clarification. These include the impacts of trans port infrastructure, of vehicle emissions, and of waste such as batteries, tyres, etc. and fuel spillage on the contamination of soil and groundwater, and the risk that this may in turn affect the quality of drink ing water and agricultural products. In addition, a better understanding is needed of the riskbenefit relationship between transport activi ties and food distribution. For example, flexible, fast, inexpensive and reliable transport systems can in crease the availability of healthy and varied diets, because fresh fruits and vegetables can be shipped throughout the year at affordable costs, reaching places where normally they would not be available. The logistics of food distribution, however, help to increase transport related health problems through emissions of air pollutants and noise, and increased risk of accidents. One important way to ensure that health issues are routinely taken on board in transport and land use decisions is to require that they be subjected to ad equate health impact assessments HIAs . This is already formally required as part of environmental impact assessments, but in practice the extent and depth of these health assessments are limited. HIAs tend to be incomplete. They should include outdoor as well as in car air pollution, vibration as well as noise, direct as well as indirect effects, and long term as well as short term consequences. They need to address the sensitivity of various subgroups, to include threshold and non threshold pollutants and possible chemical mixtures, and to consider all the various exposure pathways. Best practice for HIAs includes transparency. The public should be encouraged to participate actively in decisions on the scope of concerns to be included, the choice of alternatives to be investigated and the acceptable levels of additional risk. Public percep tions have to be acknowledged, and findings com municated in a timely and straightforward way. Special effort needs to be devoted to communicat ing the underlying assumptions and methods used, as well as the results. Adequate HIAs of transport and land use initiatives are neither trivial nor impossible, as demonstrated by recent good examples at Schiphol airport in the Netherlands and at a highway planning project in Krefeld in North Rhine Westphalia, Germany. Developing mechanisms to ensure that the full health implications of any transport proposal are adequately considered is essential. Nevertheless, even with such mechanisms in place, suboptimal deci sions may be made. A great deal depends on ensur ing that the efficient options are actually on the table in the first place. They cannot be chosen unless they make the shortlist. Impact assessment is worthless if it is not used to guide the process of policy making. An analysis of stakeholders could help identify when and how to make assessments. Relegating health to assessments that only document health effects is not enough. Costbenefit analysis will be a pivotal decision making tool for most large transport and land use decisions. Not to translate health effects into economic valuations runs the risk of marginalizing health as an issue, in favour of the financial implications of a project. For the predicted health outcomes to be an integral part of the calcu lus used in planning transport systems, every effort should be made to give them an economic value. Economic valuation is about identifying individual preferences and translating them into a money meas ure, to create a common denominator for compar ing the pros and cons. No matter how it is reached, any decision implicitly places a money value on health effects. The process of economic valuation makes these values explicit. Its approach to defin ing health costs is based broadly on the preferences of individuals and the effect on their welfare, and is measured by individuals willingness to pay to avoid those costs. A range of factors contributes to determining the size of individual willingness to pay to prevent health effects: lost wages, the costs of medical treatment, pain and inconvenience, and the increased prob ability of death. Naturally but unfortunately, esti mates of transport related health costs have often been restricted to more easily measured elements, such as medical treatment cost of illness studies or lost wages the human capital approach . They have often neglected less easily quantifiable elements, such as the cost of pain and grief, for example. Undervaluing health impact can have profound practical implications for policy. For example, the value attached to the loss of one life in Europe is usually much lower than that suggested from the economics literature, because only the loss of wages is considered in some countries. This systematic undervaluation has a dramatic ef fect on accidents, for example, discriminating against policies that would save lives. Taking the simple step of ensuring that appropriate valuations were used in every analysis of transport infrastructure and safety policies could have a major impact on reduc ing both the absolute numbers of casualties and the observed differences across European countries. The valuation of the health effects of air pollution presents a particularly challenging set of problems. At the moment, deaths caused by air pollution are often still valued the same as those from road acci dents. This is highly unlikely to be appropriate. The people at risk from the acute health effects of air pollution tend to be much older than the average accident victim, and would perhaps have died a few months later from already existing health conditions. Only recently have studies begun to con sider this aspect. The need for more sophisticated valuation meth odologies is highlighted by the growing interest of health professionals in much broader definitions of health. These encompass such phenomena as the isolation and social disjunction barrier effect , fear and stress that road traffic can generate. A further limitation of current approaches is that they focus on observable health events and out comes, observed consequences of the physical risk that is too costly or just too inconvenient to avoid. They do not take account of the cost of avertive behaviour to reduce personal exposure to risk , which is much harder to value. Each country needs to identify and act on a pack age of measures suitable for its own setting by con sidering the costs and benefits of alternative policy measures. In designing policies, a holistic approach is crucial, considering the various health consequences to gether, the health issues in combination with other factors and long term consequences as well as im mediate effects. Strategies may be beneficial for one health element but not others, for health as a whole but not for the environment, or for the short but not the long term. Numerous examples show the dangers of too narrow a perspective. Higher speeds over certain ranges reduce pollution but increase accident risks. New desulfurized fuels improve the particulate situation but generate more environmen tally damaging CO 2 . Taking a holistic approach means rejecting some misleadingly attractive op tions. Several initiatives designed to make the most of transport systems have already been taken. Policy makers, relevant organizations and groups, and au thorities at all levels must join forces and build on the relevant initiatives, learn from their experience, avoid duplication and maximize use of human re sources. Political leadership, commitment, and the ability to negotiate, develop alliances and solve prob lems are essential requirements for people address ing these complex issues. Most of all, they must have vision and a clear understanding of what it takes to achieve the desired goals. How we travel, where through and how often all have major implications for the health of our com munities. This book outlines the current under standing of the health consequences of transport: the heavy toll in deaths and serious injuries from accidents on the roads; the significant premature mortality and burden on hospital resources resulting from air pollution produced by traffic; the serious and pervasive annoyance induced by traffic noise and the learning difficulties and in crease in risk of cardiovascular disease associated with it; the missed opportunities for many health ben efits from improved physical activity through the failure widely to employ non motorized forms of transport cycling and walking; and the constraints on the development of children and neighbourhood support networks posed by heavy traffic. These effects fall disproportionately heavily on some groups of the population. Some are more exposed because the areas they live, work or move in have higher levels of pollutants or other risks, or restrict cycling and walking. Some are more vulnerable to traffic risks, due to being very young or old, or ill or disabled. Others use modes of transport associated with greater risks. Various types of transport harm can pile up in the same communities, often those already the poorest in socioeconomic and health terms. Societies will always need to make trade offs: be tween convenience and safety, between access to services and clean air and between absolute freedom to travel and better health. If we wish to travel, some kind of health price is always likely. The problem with the ill health currently generated by transport is not so much that it is substantial though this may suggest that more research is needed to find appropriate technical solutions . It is that, given the knowledge, technology and re sources available, the levels of such ill health are sig nificantly higher than is compatible with maximal social wellbeing. The reason is that health issues are not sufficiently included in peoples decisions about their lifestyle and travel or in governments deci sions about the way cities are organized and trans port infrastructure is constructed. Individuals lack of consideration of the health con sequences occurs in good part because a significant share of these consequences actually falls on others. The reasons for governments failure in this regard are less clear. They lack understanding of the nature and severity of the health effects, and effective mechanisms for informing individuals and commu nities and identifying their concerns and priorities. The administrative organization of governments and research institutions, which splits the responsibility for different aspects of transport and its effects, may reinforce the difficulty in producing comprehensive assessments and proposing holistic solutions. Governments have acted to address some of the health effects of transport; unfortunately, this ac tion has been insufficient and has had certain char acteristics limiting its effectiveness. For example, in terventions have tended to focus on the people who generate the problem rather than those who suffer its consequences, on reducing rates rather than ab solute levels, on risks rather than exposure, on health risks separately rather than as a whole, and on the environment or health, in isolation from each other. This gives rise to measures that emphasize driver safety rather than the protection of pedestrians and cyclists, that reduce noise and pollution emission rates or accident risk per kilometre rather than am bient pollution or accident level per trip, and that provide individual technological fixes rather than reductions in overall exposure to risks through sys temic changes. As a result, transport still inflicts substantial unnec essary damage on health. While gaps clearly remain in knowledge of the health impacts of transport, we know the direction and approximate size of the ex ternal costs to health and enough about some causal relationships to take action now. Governments should adopt two important related strategies to address these issues: to internalize health externalities, which involves establishing policies to regulate or encourage more optimal use of existing transport systems; and to make decisions concerning transport infrastruc ture and urban development that take appropri ate account of the health implications. Making such decisions means establishing systems that routinely, accurately and comprehensively iden tify and measure the health consequences of present and planned transport and land use strategies and projects. It also means developing and applying methods to measure the economic value of the whole range of these health consequences. Finally, it is important to consider sufficiently broad and for ward looking options in planning transport systems or how land will be used, so that strategies that are sustainable for health and the environment have a chance to be considered and accepted. To perform these two essential tasks, governments need a good understanding of the values and priori ties of the communities affected by transport and land use policies. Communities need to have access to information and be involved in the decision making process. Governments should pay special attention to groups at greater risk of transport re lated health effects, including women, elderly peo ple, children, the ill or disabled, the poor and people living or moving through areas with greater or cu mulative exposure, or using vulnerable transport modes. Cooperation across sectors of government and between countries, and clearly identified me dium and long term goals should support the im plementation of this process for change. To support governments in this process, WHO and other in ternational organizations should: collect and regularly update scientific and eco nomic information on the health effects of trans port in a way that facilitates policy decisions for example, by producing an authoritative summary of the scientific basis for the health effects of trans port, including limit values for risks and benefits, in a similar way to WHO guidelines on commu nity noise and air and drinking water quality ; monitor the health consequences of current trans port modes and policies at the local, country and international levels as part of health and environ ment information systems; and develop practical tools for the assessment of the health effects of transport and their costs. Finally, international cooperation and coordination are needed to fill the gaps in knowledge on the health effects of transport. 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Manchester, Manchester Statistical Society, 1991. 111. London, The Stationery Office, 1998. 112. London, Penguin, 1988. 113. London, Kings Fund, 1995. 114. . Paris, International Union of Railways UIC , 2000. 115. www .who .dk London99 W elcomeE.htm . Copenhagen, WHO Regional Office for Europe, 1999 accessed 14 November 2000 . We, Ministers and representatives of the European Member States of WHO 1 responsible for transport, environment and health: 1.ACKNOWLEDGE that transport activities play a significant part in life today. Transport provides us with access to goods and services, opportunities for individual mobility and bet ter quality of life, and plays an important role in the economic and social development of our communities; 2.ARE CONCERNED that the impacts which decisions about transport have on health and the environment have so far not been fully recognized. We must ensure that the wellbe ing of our communities is put first when pre paring and making decisions regarding transport and infrastructure policies; 3.RECOGNIZE that: Reliance on motorized transport, in particular road transport, continues to increase, resulting in adverse environmental and health effects. These effects may increase in the future if no effective preventive and structural actions are taken; Increasing the safety of transport and reducing the health consequences of accidents need to be given high priority; Policies on transport, environment and health need to be better coordinated, with a view to integrating them. The potential conflicts between transport and environment and health policies will increase at all levels unless effective action is taken now. There is a need to enhance cooperation and coordination be tween different sectors in central and local govern ments, as well as between governments, the public and the private sector; Until now, the health effects of transport have been dealt with separately and without regard for their cumulative effect. Further coordination with and within the health sector is needed; Consideration of the health impacts of policies has to be better integrated into approval procedures, impact assessments, and evaluations of the costs and benefits of transport plans, land use planning, and infrastructure programmes and investments; Motorized transport, and especially road and air transport users, usually do not face the full environ mental and health related costs, which can create adverse incentives and distortions in the transport market; The public is generally not sufficiently informed of the adverse environmental and health effects from motorized transport and the importance of taking individual action to alleviate the problems. We adopt this Charter, which was elaborated by ministries of transport, environment and health. This Charter sets out the principles, strategies and a plan of action to guide our policies towards achiev ing transport sustainable for health and the envi ronment. We are concerned that current patterns of transport, which are dominated by motorized road transport, have substantial adverse impacts on health as de scribed in Annex 1 . 1.In all Member States, traffic accidents, and in particular road traffic accidents, are a major cause of death and serious injury. However, success in reducing accidents in some coun tries demonstrates that it is possible to sub stantially reduce this massive health burden in all countries. 2.Road transport is a major contributor to hu man exposure to air pollution. Long term ex posure to air pollutants and levels exceeding air quality guideline values is associated with a number of adverse health impacts, includ ing effects on cardiovascular diseases and on respiratory diseases in adults and children. Such exposure may reduce life expectancy. Some pollutants such as benzene and some types of particle, increase cancer risks. 3.A considerable number of people in Europe are exposed to levels of traffic noise that cause not only serious annoyance and sleep loss but also communication problems, and even learn ing problems in children. There is emerging evidence of an association between hyperten sion and ischaemic heart diseases and high levels of noise. Ambient noise levels continue to grow due to ever increasing volumes of traf fic. 4.Forms of transport that entail physical activ ity, like cycling and walking, separately or in conjunction with public transport, offer sig nificant positive health gains; however, these transport modes have often been overlooked in planning and decision making. 5.Heavy road traffic and major transport infra structures can divide communities, reduce op portunities for social interactions, and worsen peoples quality of life and can be associated with reduced interpersonal networks of sup port at local level. 6.Transport activities can contaminate soil, wa ter and air, through accidents involving dan gerous goods and contamination from transport infrastructures, or by heavy metals from vehicle exhausts, de icing substances, fuel spillages, release of fuels and other pollutants from road and rail vehicles, ships and aircraft, etc. 7.Everyone is exposed to some degree of health risk from transport, but the adverse health ef fects fall disproportionately on the most vul nerable groups in our societies: people with disabilities or hearing or sight impairments; older people; the socially excluded; children and young people; and people living or work ing in areas of intensified and cumulative air pollution and noise. We are encouraged by the initiatives already taken through the adoption of a number of political dec larations, conventions and protocols as listed in Annex 2 , and in particular WHOs policy on Health for All, the Helsinki Declaration on Action for En vironment and Health in Europe, and the Vienna Declaration and Programme of Joint Action on Transport and the Environment adopted under the auspices of the United Nations Economic Commis sion for Europe UN ECE , as well as the EU legis lation in this area. We reaffirm the commitments already made in the fields of transport, environment and health, and we acknowledge the steps already taken towards achieving transport that is sustain able for health and the environment. However, de spite these progressive steps we are concerned that the impacts which decisions about transport have on health and the environment have so far not been fully recognized. 8.We recognize the need to strengthen the en forcement of current road safety legislation. 9.We encourage the ratification of UN ECE le gally binding instruments relevant to trans port, environment and health by Member States that have not yet done so. 10.We are concerned that more sustainable modes of transport, especially public transport and goods transport by rail, are losing market share to road transport in many countries. This trend is enhanced by the fact that the major ity of transport infrastructure investment is allocated to road infrastructures, not least in the countries in transition. We emphasize the urgent need to take the next step in adding value to efforts to achieve sus tainable development in transport, by fully integrating health requirements and involv ing environment and health authorities in decision making on transport, land use and infrastructure policies at transnational, na tional, subnational and local levels. We have decided to incorporate the principles and approaches of sustainable development beneficial for health and the environment into our policies with relevance for transport as described in Annex 3 , in particular the following: sustainability; the precautionary principle; prevention; protection and promotion of health and safety; the polluter pays principle, including internali zation of externalities; multisectoral integration of environment and health requirements and involvement of health authorities in decision making on transport, land use and infrastructure policies; equity; public participation and public access to infor mation; subsidiarity; efficiency. Following these principles and approaches, we will incorporate guiding strategies for moving towards transport sustainable for health and the environment into our transport related policies, in particular ap plying synergistic combinations of the following key strategy elements: 11.reducing the need for motorized transport by adaptation of land use policies and of urban and regional planning; 12.shifting transport to environmentally sound and health promoting modes; 13.implementing best available technologies and best environmental and health standards; 14.applying strategic health and environmental indicators and impact assessments, with the involvement of environmental and health au thorities; 15.relating the costs of transport more closely to mileage travelled and internalizing transport related environmental and health costs and benefits; 16.raising awareness of transport and mobility sustainable for health and the environment, including efficient driving behaviour; 17.applying innovative methodologies and moni toring tools; 18.establishing partnerships at international, na tional, subnational and local levels; 19.promoting pilot projects and research pro grammes on transport sustainable for health and the environment; 20.providing information to the public and in volving them in relevant decision making processes. Having decided to establish this plan of action in order to collaborate and cooperate on making trans port sustainable for health and the environment and to further the UN ECE Vienna Declaration and Programme of Joint Action on Transport and the Environment, following the principles, approaches and guiding strategies listed in section III, WE WILL PERFORM the actions set out in this plan of action and incorporate the recommenda tions of WHO into our transport and transport related policies; and WE REQUEST the WHO Regional Office for Europe, in collaboration with other international bodies, to perform the international actions as set out in this plan of action and undertake to support those WHO efforts, within the means available. We will: 21.Pursue multisectoral cooperation and ensure that environment and health requirements are integrated and their authorities are both in volved in transport related decision making processes, such as those on transport, water and land use planning, infrastructure invest ment programmes and policy decisions. 22.Establish the concepts and long term goals of transport sustainable for health and the envi ronment, building on the work already done in the relevant fora. 23.Adopt targets as listed in Annex 4, based on scientific knowledge and work and the guide lines of WHO and incorporate them into the relevant policies to reduce : mortality, cardiovascular and respiratory problems and cancer risks and neuro developmental problems from transport related air pollution; mortality and morbidity from transport ac cidents; risk of cardiovascular and other diseases from lack of physical exercise; human exposure to noise. 24.Develop measurement methodologies and data collection processes to monitor progress towards achieving the targets in Annex 4. Such monitoring should also underpin the devel opment of policies to reduce the adverse health and environmental impacts of transport. 25.Review and where necessary develop further strategies or introduce national action plans to ensure the proper integration of health and environment concerns into transport, and land use strategies, in particular, through the fur ther development of National Environmen tal Health Action Plans NEHAPs , and to promote similar actions at the sub national and local levels. 26.Ensure that health authorities take full account of the impact on transport of their own poli cies. 27.Develop further or introduce policies to re duce air, soil and water pollution, accidents and noise, greenhouse gas emissions and the damaging of forests associated with transport and its infrastructures airports, motorways, railways, terminals, harbours, petrol stations, etc. , in similar ways to other major indus trial sources. 28.Ensure that synergistic effects are attained be tween strategies chosen to pursue the Kyoto targets for reduction of greenhouse gases and strategies for the reduction of other air pol lutants of health concern, paying special at tention to emissions from diesel engines. We call on WHO, in cooperation with other inter national organizations, to: 29.Develop scientific guidelines for the attain ment of transport sustainable for health and the environment, and in particular for the integration of environment and health require ments and targets into policies and plans, based on knowledge of the full and combined impacts of transport related health risks, in cluding the establishment of threshold values to protect public health, where possible. We will: 30.Develop and implement policies to promote modes of transport which lead to health and environment benefits, aiming at a shift to modes of transport with lower specific emis sions and accident risks. In particular, we will promote safe and environmentally friendly cycling and walking by providing safe infra structure and networks, implementing meas ures for traffic management, enforcing speed controls and speed limits that are appropriate to local circumstances, and designing roads and settlements taking into account the needs of pedestrians and cyclists. 31.Reduce the need for motorized transport by adapting land use policies and urban and re gional development plans to enable people to have easy access to settlements, housing and working areas, and shopping and leisure fa cilities by cycling, walking and public trans port. 32.Raise the attractiveness of public transport, walking and cycling, and promote intermo dality between them, not least by prioritizing public transport, walking and cycling in con nection with the extension of infrastructure. 33.Provide incentives to use the best available technologies and encourage ambitious vehi cle emission standards and fuel quality require ments, in order to improve safety and reduce air pollutants, noise and fuel consumption. We call on WHO, in cooperation with other inter national organizations, to: 34.Assess and provide information about the pub lic health impacts of different modes of transport, in terms of health benefits and disbenefits. 35.Quantify the consequences for public health of increasing levels of physically active modes of transport, notably walking and cycling. We will: 36.Assess the health and environmental impacts of policies, strategies, programmes, projects and legal measures with implications for trans port and mobility, and ensure that public health authorities are involved in these assess ments at all levels. 37.Support the implementation of these assess ments as part of national and international procedures for making decisions about invest ments and infrastructure programmes. We call on the World Bank, the European Invest ment Bank, the European Bank for Reconstruction and Development and other investment institutions to: 38.Carry out environmental and health impact assessments of infrastructure projects with im plications for transport and land use planning supported by them. We call on WHO to: 39.In cooperation with UN ECE, the United Na tions Environment Programme UNEP and other relevant international organizations, develop guidelines for making health impact assessments of policies, strategies, pro grammes, projects and legal measures with implications for transport. 40.Encourage the greater use and integration of health impact assessments with environmen tal impact assessments by disseminating tools and methods, sharing good practice, and pro viding education and expert training. We will: 41.Consider the health cost implications of in frastructure investment and land use planning and their consequences in terms of transport and the need for mobility, taking account not only of direct health costs but also of the costs of not adopting health promoting alternatives. 42.Promote, implement and review policies de signed to internalize the health and environ mental externalities external costs generated by transport activities. These policies will also include measures to ensure that transport costs more closely reflect marginal costs. 43.Ensure that policies introduced to promote transport that is sustainable for health and the environment are cost effective, taking all costs into account. 44.Promote the progressive suppression of subsi dies for polluting modes of transport. We call on WHO, in cooperation with other inter national organizations, to: 45.Develop comprehensive guidance on meth ods and practical tools to estimate the costs and benefits of the health consequences of transport decisions. We will: 46.Identify groups, time periods, environments and areas at higher risk of experiencing the adverse health impacts of transport, taking into account criteria to be proposed by WHO, and monitor relevant health impacts among these groups as described below. 47.Develop, implement and monitor specific policies and measures to protect these groups at higher risk of experiencing the adverse health impacts of transport. We call on WHO, in cooperation with other inter national organizations, to: 48.Develop methods for assessing and monitor ing health effects in groups at higher risk of experiencing adverse transport related im pacts. 49.Provide information and develop guidance on transport related health targets, threshold val ues and measures regarding populations at higher risk due to: a specific vulnerability children, the elderly or people suffering from diseases, refugees and immigrants ; b higher exposure levels resulting from geo graphical and topographical conditions, settlement characteristics, travel and oc cupation; c disability and social disadvantage as a re sult of lack of access to facilities, disrup tion of communities and greater exposure to accident risks. We will: 50.Promote international collaboration on re search and standardized measurement pro grammes and promote the development of cost effective measures against the adverse health effects of noise, pollutants and poten tial carcinogens, such as emissions from die sel engines and fine and ultrafine particles. 51.Promote international collaboration on meas urement programmes at the point of exposure and support research into the links between transport indicators, exposures and health. We call on WHO to: 52.Promote further investigation of the health ef fects of pollutants, pollutant mixes, noise and other hazards from transport where evidence is incomplete and human exposure is signifi cant e.g. diesel engine emissions, and espe cially fine and ultrafine particles , including their possible carcinogenic risk potential. 53.Propose guideline values where possible for ambient levels of and exposure to pollutants and noise, in particular for those pollutants for which guideline values are not yet avail able, with a view notably to informing the review of the European Communitys air qual ity standards before 2005. 54.Promote investigation of the health effects of exposure to pollutant mixtures, noise and other hazards, including their combined ef fects inside motor vehicles, on pavements, on bicycles, and due to living and or working near busy roads, and elaborate guidelines includ ing guideline values for these exposure lev els. 55.Further develop guidelines regarding the health risks of levels of exposure to fine and ultrafine particles based on assessment of their health effects, with particular attention to their number, mass, size, surface area and compo sition. 56.Assess the evidence for health risks from soil and water contamination due to transport and its infrastructures, and make recommenda tions regarding the possibility of establishing safe limits and the need to establish targets. 57.Promote investigation of the health and psy chosocial effects of participation in modern traffic. We will: 58.Implement and, if needed, further develop sys tems for monitoring transport related expo sures and impacts on environment and health. We call on WHO, in cooperation with other inter national organizations, to: 59.Develop indicators and guidelines for meas uring and monitoring the health effects of transport on the general population and in groups and areas at higher risk, and assess the effectiveness of interventions to minimize those effects. We will: 60.Promote research programmes and pilot projects and incorporate the results in our transport, environment, land use and health policies, especially in liaison with WHO. 61.Establish conditions for pilot projects where local measures are employed to reduce pollu tion and other negative impacts from trans port, for example by promoting environ mentally enhanced vehicles, restricting the circulation of high polluting vehicles, and promoting cycling, walking and innovative public transport, local speed limits and park ing restrictions. 62.Enhance our endeavours to bridge the gap which still exists between our knowledge of strategies that can be used to move towards transport sustainable for health and the envi ronment, on the one hand, and current trans port, land use and infrastructure patterns, on the other. We call on WHO, in cooperation with other inter national organizations, to: 63.Facilitate the development of a programme of research with a special focus on the adverse health effects of transport and the positive health effects of physically active modes of transport, notably walking and cycling, and promote pilot projects related to these issues. 64.Cooperate with countries on pilot testing health impact assessment methods, evaluat ing costs and benefits of policy interventions, and supporting training initiatives and infor mation dissemination programmes. We will: 65.Ensure public access to health related infor mation on and participation in decision mak ing on transport projects, programmes, policies, plans and regulations, and ensure access to justice in these matters in accord ance with the application of the provisions of the rhus Convention. This should apply notably to all actions taken under this Char ter. 66.Promote the development and application of: a information, education and communica tion campaigns, including those of inter national institutions, to raise the aware ness among stakeholders and decision makers of the need for transport sustain able for health and environment; b information campaigns targeted at groups using the least environmentally friendly modes of transport. 67.Contribute to WHOs information dissemi nation efforts and provide and disseminate national and regional public information on transports environment and health impacts, and on strategies and tools for transport sus tainable for health and the environment, tar geting specific population groups. We call on WHO to: 68.Develop an information, education and com munication strategy to increase public aware ness of the different impacts of transport on human health and to facilitate the choice of modes of transport sustainable for health and the environment. 69.Establish a transnational WHO network for sharing information and disseminating good practice with regard to transport sustainable for health and the environment. We will: 70.Cooperate with and so far as possible support these countries in promoting transport sus tainable for health and the environment. 71.Pay attention to meeting the challenges of in tegrating transport, environment and health in the economies in transition, in order to avoid and reduce the environmental health impacts of increasing transport. We call on WHO, in cooperation with other inter national organizations, to: 72.Direct special guidance and support to these countries. in partnership the plan of ac tion set out in this Charter and make appropriate arrangements for its follow up, so far as possible using existing mechanisms to follow up and moni tor transport, environment and health decisions, such as the European Environment and Health Committee EEHC , national environmental health action plans NEHAPs , WHOs European minis terial conferences on environment and health, the UN ECE Vienna Declaration and Programme of Joint Action on Transport and the Environment, the Organisation for Economic Co operation and Development OECD Transport and Environment Working Group, and the Environment for Europe process. We will: 73.Collaborate with other countries on trans boundary and international issues, taking into account the guidelines and tools proposed by WHO and other international organizations. 74.Promote enhanced cooperation by WHO with other intergovernmental bodies such as UN ECE, UNEP, the European Community and transnational bodies such as the Central European Initiative CEI , OECD, the Euro pean Conference of Ministers of Transport ECMT , the European Environment Agency EEA , nongovernmental organizations NGOs and the private sector. 75.Encourage the public, NGOs and the private sector and support local authorities and rel evant city networks to engage in efforts to at tain transport sustainable for health and the environment that promote and actively con tribute to implementation of the plan of ac tion in this Charter. We will, in cooperation with WHO and other in ternational organizations: 76.Follow up the implementation of the decisions contained in this Charter by: c using the national focal points established for the implementation of the UN ECE Vienna Declaration and Programme of Joint Action on Transport and the Envi ronment and designating additional con tact points for health before the end of 1999; d ensuring that these focal contact points link effectively with the follow up pro cesses of WHOs European ministerial conferences on environment and health, the UN ECE Vienna Declaration and Pro gramme of Joint Action on Transport and the Environment and, nationally, with Habitat Committees; e setting up a steering group of interested Member States and international organi zations to push forward the implementa tion of this Charter and to facilitate cross sectoral coordination and international cooperation of public and private institu tions, and to coordinate and cooperate closely with the UN ECE Joint Meeting on Transport and Environment JMTE . 77.Support, where needed, WHO and the other agencies in compiling an overview of existing agreements and legal instruments in the field of transport, environment and health, as speci fied below, and consider the proposals on fur ther needed action which they make based on this overview. 78.Regularly monitor the links between transport, environment, land use and health using avail able relevant information and report on the status of these links in the Region. 79.Monitor progress towards targets concerning transport sustainable for health and the envi ronment and towards the integration of health and environment concerns into water, land use and transport policies, as part of existing in ternational review processes e.g. OECD and UN ECE environmental performance re views . 80.Assist the steering group of interested Mem ber States and international organizations within the framework of EEHC. 81.Disseminate information about new scientific evidence concerning the effects of transport on the environment and health, about meth ods of and experience with environmental health impact assessment, and about economic valuations of transport related health effects. 82.Update targets, guidelines and other tools rel evant to implementation of this Charter, and update Charter related research priorities, in particular in liaison with the international platform on research. We call on UN ECE JMTE to: 83.Coordinate and closely cooperate with the steering group mentioned under sub para graph 4 c above. We call on WHO, jointly with UN ECE and in cooperation with other international organizations, to: 84.Provide an overview of relevant existing agree ments and legal instruments, with a view to improving and harmonizing their implemen tation and further developing them as needed. A report on this overview should be submit London, 16 June 1999 Rt Hon Tessa Jowell, MPRt Hon Michael Meacher, MP Minister of State for Public HealthMinister for the Environment United KingdomUnited Kingdom Lord Whitty of CamberwellDr J.E. Asvall Parliamentary Under Secretary of StateWorld Health Organization Department of the Environment,Regional Director for Europe Transport and the Regions United Kingdom ted at the latest by spring 2000, recommend ing which further steps are needed. That re port should cover the possibility of new non legally binding actions and the feasi bility, necessity and content of a new legally binding instrument e.g. a convention on transport, environment and health , focusing on bringing added value to, and avoiding over laps with, existing agreements. Current yearly numbers of road traffic accidents in the WHO European Region are still unacceptably high, with around 2 million accidents with inju ries, 120 000 deaths and 2.5 million injured peo ple. One in every three road traffic deaths involves a person younger than 25 years. Road accidents account for most fatal transport ac cidents, both in terms of absolute number of deaths and of deaths per kilometre travelled. For example, in 1995, in the European Union 44 000 people were killed in road accidents, while 936 people died in railway accidents. Death rates per thousand million kilometres travelled were about three times higher for road than for rail transport 11 and 3.4 fatalities per thousand million kilometres, respectively . Worldwide statistics on air safety report that in 1997 there were a total of 916 fatalities in air accidents involving scheduled flights, corresponding to 0.4 fatalities per thousand million kilometres of travel worldwide. As for lives lost at sea, worldwide statis tics report a total of 690 fatalities in 1996. Traffic accident mortality rates have been falling over the past decade across the Region, but there is still an almost ten fold difference between the highest and lowest rates. Vulnerable road users such as pedestrians and cy clists account for 3035 of deaths. The severity of accidents among pedestrians is almost twice as high as that in car occupants. It is estimated that in European cities around 80 000 adult deaths a year are related to long term ex posure to traffic related air pollution, using the pro portion of ambient PM 10 concentration due to traf fic as an indicator. Both short and long term WHO air quality guide line values are frequently and considerably exceeded in the European Region, in particular for ozone, NO 2 and particulate matter. New evidence is emerging that children living near roads with heavy vehicle traffic have about a 50 higher risk of suffering from respiratory symptoms than children living in areas with low traffic. Car occupants have a significantly higher level of exposure to engine emissions than people outside vehicles. In 1998, the California Air Resources Board identi fied diesel exhaust as a Toxic Air Contaminant based on a review of animal and epidemiological studies, which strongly suggest a causal relationship between occupational diesel exhaust exposure and lung cancer. Already in 1989, the International Agency for Research on Cancer IARC had con cluded that diesel engine exhaust is probably carci nogenic to humans Group 2A , while gasoline engine exhaust was classified as possibly carcino genic to humans Group 2B . Transport and in particular road traffic, is the main cause of human exposure to ambient noise. The proportion of the population in the European Region exposed to high noise levels equivalent to 65 dBLA eq over 24 hours increased from 15 to 26 between 1980 and 1990. About 65 of the European population is estimated to be exposed to noise levels leading to serious an noyance, speech interference and sleep disturbance 5565 dBLA eq over 24 hours . Children chronically exposed to loud noise e.g. in the proximity of airports show impaired acquisi tion of reading skills, attention and problem solv ing ability. Noise can interfere with mental activities requiring attention, memory and the ability to deal with com plex analytical problems. Adaptation strategies tune out ignore noise and the efforts needed to main tain performance have been associated with high levels of stress hormones and blood pressure. There is emerging evidence of an association be tween hypertension and ischaemic heart diseases and high levels of noise. Lack of physical activity is one of the major risk factors for coronary heart disease, which is the lead ing cause of mortality in Europe. On the other hand, walking and cycling as daily activities can promote health by providing physical activity, decreasing noise and air pollution. The health benefits of regular physical activity can be summarized as: 50 reduction in the risk of developing coronary heart diseases i.e. a similar effect to not smok ing ; 50 reduction in the risk of developing adult dia betes; 50 reduction in the risk of becoming obese; 30 reduction in the risk of developing hyper tension; 10 8 mm Hg decline in blood pressure in hyper tensive subjects i.e. a similar effect to that ob tained from antihypertensive drugs . Other effects include reduced osteoporosis, relief of symptoms of depression and anxiety, and the pre vention of falls in the elderly. A total of 30 minutes brisk walking or cycling on most days of the week, even if carried out in 1015 minute episodes, is effective in providing these health benefits. The average trip by walking in Europe is about 1.5 km and the average cycling trip is about 3.5 km, each taking about 15 minutes to make: two such trips each day would be enough to provide the rec ommended daily dose of physical activity. Certain patterns of transport have a broad range of effects on mental health, including risk taking and aggressive behaviours, depression and post traumatic psychological effects of accidents. High levels of traffic can cause social isolation and limit interpersonal networks of support, factors which have been found to be associated with higher mortality and morbidity in the elderly. Children who have the opportunity of playing un hindered by street traffic and without the presence of adults have been found to have twice as many social contacts with playmates in the immediate neighbourhood as those who could not leave their residence unaccompanied by adults due to heavy traffic. The fear of accidents is reported by parents as being the main reason for taking children to school by car. This hinders the development of childrens in dependence and reduces their opportunities for so cial contact. It also has an influence on childrens attitudes towards car use and personal mobility in adulthood. The lack of physical activity, including walking and cycling, is associated with mental ill health, includ ing depression. Transport accidents with dangerous goods can lead to localized environment and health risks from con tamination of air, water and soil. Transport infrastructures, heavy metals from vehi cle exhaust and de icing substances, vehicle waste e.g. old cars, tires, batteries , fuel spillages, as well as tire and road abrasion, can cause contamination of soil and groundwater, which may affect the qual ity of drinking water and of agricultural products. Sewage released from ships can cause microbiologi cal contamination of water and shellfish. Release of ballast water i.e. water which fills empty oil tanks leads to contamination of water by hydrocarbons. The impacts of transport on health fall dispropor tionately on certain groups of the population. Some are more vulnerable to traffic risks, due to old or young age, to illness or disability. Others use modes of transport associated with greater risks e.g. mo torcycles . Some are more exposed because the ar eas they live, work or move in have higher levels of pollutants and noise e.g. due to the intensifying effect of specific geographical and topographical conditions and settlement characteristics or other risks, or restrict cycling and walking. Many disbenefits of transport can accumulate in the same communities, often those that already have the poor est socioeconomic and health status. The 1979 Convention on Long range Transbound ary Air Pollution and its Protocols, and: the 1984 Protocol on the Long term Financing of the Cooperative Programme for Monitoring and Evaluation of Long range Transboundary Air Pollution the 1988 Protocol on the Control of Emissions of Nitrogen Oxides or their Transboundary Fluxes the 1991 Protocol on the Control of Emissions of Volatile Organic Compounds or their Trans boundary Fluxes the 1994 Protocol on Further Reduction of Sul phur Emissions the 1998 Protocol on Heavy Metals the 1998 Protocol on Persistent Organic Pollu tants The 1991 Convention on Environmental Impact Assessment in a Transboundary Context Espoo Convention The 1998 Convention on Access to Information, Public Participation in Decision making and Access to Justice in Environmental Matters rhus Con vention The European Agreement concerning the Interna tional Carriage of Dangerous Goods by Road ADR , of 30 September 1957 Protocol amending Article 1 a , Article 14 1 and Article 14 3 of the European Agreement of 30 Sep tember 1957 concerning the International Carriage of Dangerous Goods by Road ADR , of 28 Octo ber 1993 Convention on Civil Liability for Damage caused during Carriage of Dangerous Goods by Road, Rail and Inland Navigation Vessels CRTD , of 10 Oc tober 1989 Agreement on the International Carriage of Perish able Foodstuffs and on the Special Equipment to be Used for such Carriage ATP , of 1 September 1970 Convention on Road Traffic, of 19 September 1949 Convention on Road Traffic, of 8 November 1968 Protocol on Road Signs and Signals, of 19 Septem ber 1949 Convention on Road Signs and Signals, of 8 No vember 1968 European Agreement supplementing the Conven tion on Road Traffic 1968 , of 1 May 1971 European Agreement supplementing the Conven tion on Road Signs and Signals 1968 , of 1 May 1971 European Agreement on the application of Article 23 of the Convention on Road Traffic 1949 con cerning the dimensions and weights of vehicles per mitted to travel on certain roads of the contracting parties, of 16 September 1950 European Agreement supplementing the Conven tion on Road Traffic 1949 and the Protocol on Road Signs and Signals 1949 , of 16 September 1950 European Agreement on Road Markings, of 13 December 1957 Protocol on Road Markings, additional to the European Agreement supplementing the Conven tion on Road Signs and Signals, of 1 March 1973 Agreement on Minimum Requirements for the Is sue and Validity of Driving Permits APC , of 1 April 1975 Agreement concerning the Adoption of Uniform Technical Prescriptions of Wheeled Vehicles, Equip ment and Parts which can be fitted and or be used on Wheeled Vehicles and the Conditions for Re ciprocal Recognition of Approvals granted on the basis of these Prescriptions, of 20 March 1958. This includes the relevant technical regulations listed in the Agreement Agreement concerning the Adoption of Uniform Conditions for Periodical Technical Inspection of Wheeled Vehicles and the Reciprocal Recognition of such Inspections, of 1997 Agreement concerning the Establishing of Global Technical Regulations for Wheeled Vehicles, Equip ment and Parts which can be fitted and or be used on Wheeled Vehicles Declaration on the construction of main interna tional traffic arteries, of 16 September 1950 European Agreement on Main International Traffic Arteries AGR , of 15 November 1975 European Agreement on Main International Rail way Lines AGC , of 31 May 1985 European Agreement on Important International Combined Transport Lines and Related Installations AGTC , of 1 February 1991 Protocol on Combined Transport on Inland Water ways to the European Agreement on Important In ternational Combined Transport Lines and Related Installations AGTC of 1991, of 1997 European Agreement on Main Inland Waterways of International Importance AGN , of 19 January 1996 European Agreement concerning the Work of Crews of Vehicles engaged in International Road Trans port AETR , of 1 July 1970 Convention on the Taxation of Road Vehicles for Private Use in International Traffic, of 18 May 1956 Convention on the Taxation of Road Vehicles En gaged in International Passenger Transport, of 14 December 1956 Convention on the Taxation of Road Vehicles En gaged in International Goods Transport, of 14 De cember 1956 Convention on the Contract for the International Carriage of Goods by Road CMR , of 19 May 1956 Protocol to the Convention on the Contract for the International Carriage of Goods by Road CMR , of 5 July 1978 Convention on the Contract for the International Carriage of Passengers and Luggage by Road CVR , of 1 March 1973 Protocol to the Convention on the Contract for the International Carriage of Passengers and Luggage by Road CVR , of 5 July 1978 General Agreement on Economic Regulations for International Road Transport, of 17 May 1954 Convention relating to the Unification of Certain Rules concerning Collisions in Inland Navigation, of 15 March 1960 Convention on the Registration of Inland Naviga tion Vessels, of 25 January 1965 Convention on the Measurement of Inland Navi gation Vessels, of 15 February 1966 Convention relating to the Limitation of Liability of Owners of Inland Navigation Vessels CLN , of 1 March 1973 Protocol to the Convention relating to the Limita tion of the Liability of Owners of Inland Naviga tion Vessels CLN , of 5 July 1978 Convention on the Contract for the International Carriage of Passengers and Luggage by Inland Wa terways CVN , of 6 February 1976 Protocol to the Convention on the Contract for the International Carriage of Passengers and Luggage by Inland Waterways CVN , of 5 July 1978 Convention on the Protection and Use of Trans boundary Watercourses and International Lakes, of 17 March 1992 Helsinki Convention Concerning International Carriage by Rail COTIF , 9 May 1980 Berne , including: Uniform Rules concerning the Contract for In ternational Carriage of Passengers and Luggage by Rail CIV Uniform Rules concerning the Contract for In ternational Carriage of Goods by Rail CIM Regulations concerning the International Carriage of Dangerous Goods by Rail RID Framework Convention on Climate Change, of 9 May 1992 New York Kyoto Protocol to the Framework Convention on Climate Change, of 11 December 1997 Vienna Convention for the Protection of the Ozone Layer, of 22 March 1985 Montreal Protocol on Substances that Deplete the Ozone Layer, of 16 September 1987 and adjust ments adopted in London 1990 , Copenhagen 1992 , Vienna 1995 and Montreal 1997 Basel Convention on the Control of Transboundary Movements of Hazardous Wastes and their Disposal, of 22 March 1989 Convention on the Prior Informed Consent Pro cedure for Certain Hazardous Chemicals and Pesti cides in International Trade PIC Convention , 1998 Rotterdam Council Directive 85 337 EEC of 27 June 1985 on the assessment of the effects of certain public and private projects on the environment Council Directive 97 11 EC of 3 March 1997 amending Directive 85 337 EEC on the assessment of the effects of certain public and private projects on the environment Directive 70 156 EEC of 6 February 1970 on the approximation of the laws of the Member States relating to type approval of motor vehicles and their trailers, as amended Directive 71 320 EEC of 26 July 1971 on the ap proximation of the laws of the Member States relat ing to the braking devices of certain categories of motor vehicles and of their trailers, as amended Directive 74 408 EEC relating to the interior fit tings of motor vehicles strengths of seats and of their anchorages , as amended Directive 76 115 EEC relating to anchorages for motor vehicle safety belts, as amended Directive 77 541 EEC relating to safety belts and restraint systems for motor vehicles, as amended Council Regulation 3820 85 EEC of 20 Decem ber 1985 on the harmonisation of certain social leg islation relating to road transport Council Regulation 3821 85 EEC of 20 Decem ber 1985 on recording equipment in road transport Directive 89 459 EEC of 18 July 1989 on the ap proximation of the laws of the Member States relat ing to the tread depth of tyres of certain categories of motor vehicles and their trailers, as amended Directive 91 671 EEC on the approximation of laws relating to compulsory use of safety belts in vehicles of less than 3.5 tonnes Directive 92 6 EEC on the installation and use of speed limitation devices Directive 96 53 EC of 25 July 1996 laying down for certain vehicles circulating within the Commu nity the maximum authorized dimensions in na tional and international traffic and the maximum authorized weights in international traffic Directive 96 96 EC of 20 December 1996 on the approximation of the laws of the Member States relating to roadworthiness tests for motor vehicles and their trailers Council Directive 76 914 EEC of 16 December 1976 on the minimum level of training for some road transport drivers Council Directive 91 439 EEC of 29 July 1991 on driving licences, amended by: Council Directive 94 72 EC of 19 December 1994 Council Directive 96 47 EC of 23 July 1996 Council Directive 97 26 EC of 2 June 1997 Directive 70 220 EEC on measures to be taken against air pollution by gases from positive ignition engines of motor vehicles, as amended, including: Directive 74 209 EEC; Directive 77 102 EEC; Directive 78 665 EEC; Directive 83 351 EEC; Directive 88 76 EEC; Directive 88 609 EEC; Di rective 89 458 EEC; Directive 91 441 EEC the Consolidated Directive ; Directive 94 12 EC; Directive 96 69 EC; Directive 98 69 EC Directive 72 306 EEC on measures to be taken against emissions of pollutants from diesel engines for use in motor vehicles, as amended Directive 75 716 EEC on the approximation of the laws of the Member States on the sulphur content of certain liquid fuels, as amended by Directive 87 219 EEC Directive 78 611 EEC on the lead content of pet rol Directive 80 779 EEC on air quality limit values and guide values for sulphur dioxide and suspended particulates Directive 82 884 EEC on limit values for lead in the air Directive 85 203 EEC on air quality standards for nitrogen dioxide Directive 85 210 EEC on the approximation of the Member States legislation on the lead content of petrol, and the introduction of lead free petrol Directive 85 536 EEC of 5 December 1985 on crude oil savings through the use of substitute fuel components in petrol, as amended Directive 88 77 EEC on the approximation of the laws of the Member States relating to the measures to be taken against the emissions of gaseous pollut ants from diesel engines for use in vehicles, as amended by Directive 91 542 EEC Directive 89 427 EEC on limit values and guide values of air quality for sulphur dioxide and sus pended particulates Directive 92 55 EC on inspection and maintenance Directive 92 72 EEC on air pollution by ozone Directive 93 12 EEC on the quality of petrol and diesel fuels, as amended by Directive 98 70 EC Directive 94 63 EC of 20 December 1994 on the control of volatile organic compound VOC emis sions resulting from the storage of petrol and its dis tribution from terminals to service stations Directive 96 62 EC of 27 September 1996 on am bient air quality assessment and management Air quality framework directive , with its daughter di rectives Council Decision 97 101 EC of 27 January 1997 establishing a reciprocal exchange of information and data from networks and individual stations measuring ambient air pollution within the Mem ber States Directive 70 157 EEC of 6 February 1970 on the approximation of the laws of the Member States re garding permissible sound levels and exhaust sys tems of motor vehicles, as amended by Directive 84 424 EEC Directive 78 1015 EEC of 23 November 1978 on the approximation of the laws of the Member States regarding permissible sound levels and exhaust sys tems of motor cycles, as amended by Directive 89 235 EEC; Directive 92 97 EEC Directive 80 51 EEC of 20 December 1979 on the approximation of the laws of the Member States re garding permissible sound levels of subsonic airplanes Directive 89 629 EEC of 4 December 1989 regard ing permissible sound levels of subsonic airplanes for civil aviation Directive 92 14 EEC of 2 March 1992 regarding limitations to the exploitation of airplanes, relevant to Annex 16 of the Convention on International Civil Aviation, volume 1, second part, chapter 2, second edition 1988 , as amended by Directive 98 20 EC of 30 March 1998 Directive 96 20 EC of 27 March 1996 to adapt in the light of technical progress Directive 70 157 EEC of 6 February 1970 on the approximation of the laws of the Member States regarding permissible sound levels and exhaust systems of motor vehicles Directive 97 24 EC of 17 June 1997 on certain components and characteristics of two or three wheel motor vehicles Directive 76 135 EEC of 20 January 1976 on re ciprocal recognition of navigability licences for in land waterway vessels Directive 82 714 EEC of 4 October 1982 laying down technical requirements for inland waterway vessels Directive 79 115 EEC of 21 December 1978 con cerning pilotage of vessels by deep sea pilots in the North Sea and English Channel Regulation EEC No. 613 91 of 4 March 1991 on the transfer of ships from one register to another within the Community, as amended by Commis sion Regulation EEC No. 2158 93 Council Decision 92 143 EEC of 25 February 1992 concerning radio navigation systems for Europe Directive 93 75 EEC of 13 September 1993 con cerning minimum requirements for vessels bound for or leaving Community ports and carrying dan gerous or polluting goods, as amended by Directive 96 39 EC of 19 June 1996; Directive 97 34 EC of 6 June 1997; Directive 98 55 EC of 17 July 1998; Directive 98 74 EC of 1 October 1998 List of competent authorities designated by Mem ber States to which the information and notifica tions provided for in Council Directive 93 75 EEC of 13 September 1993 concerning minimum re quirements for vessels bound for or leaving Com munity ports and carrying dangerous or polluting goods, shall be addressed OJ No. C 65 of 1 March 1997, p.3, and modification of the list in OJ No. C 150 of 16 May 1998, p.3 Council Regulation EC No. 2978 94 of 21 No vember 1994 on the implementation of IMO reso lution A.747 18 on the application of tonnage measurement of ballast spaces in segregated ballast oil tankers Directive 94 57 EC of 22 November 1994 on com mon rules and standards for ship inspection and survey organizations and for the relevant activities of maritime administrations, as amended by Com mission Directive 97 58 of 26 September 1997 Commission Decision 96 587 EC of 30 Septem ber 1996 on the publication of the list of recog nized organizations which have been notified by Member States in accordance with Directive 94 57 EC, as amended by Commission Decision 98 403 EC of 12 June 1998 Commission Decision of 22 April 1998 on the rec ognition of the Hellenic Register of Shipping in ac cordance with Council Directive 94 57 EC Directive 94 58 EC of 22 November 1994 on the minimum level of training of seafarers, as amended by Directive 98 35 EC of 25 May 1998 Directive 95 21 EC of 19 June 1995 concerning the enforcement, in respect of shipping using Com munity ports and sailing in the waters under the jurisdiction of the Member States, of international standards for ship safety, pollution prevention and shipboard living and working conditions port State control , as amended by Directive 98 25 EC of 27 April 1998; Directive 98 42 EC of 19 June 1998 Directive 96 40 EC of 25 June 1996 establishing a common model for an identity card for inspectors carrying out port State control Council Regulation EC No. 3051 95 of 8 Decem ber 1995 on the safety management of roll on roll off passenger ferries ro ro ferries , as amended by Commission Regulation EC No. 179 98 of 23 January 1998 Directive 96 98 EC of 20 December 1996 on ma rine equipment, as amended by Directive 98 85 EC of 11 November 1998 Directive 97 70 EC of 11 December 1997 setting up a harmonised safety regime for fishing vessels of 24 metres in length and over Directive 98 18 EC of 17 March 1998 on safety rules and standards for passenger ships Directive 98 41 EC of 18 June 1998 on the regis tration of persons on board passenger ships Convention on International Civil Aviation, signed at Chicago on 7 December 1944, and relevant protocols and agreements, and in particular its An nex 16 on Environmental protection International Convention for the Safety of Life at Sea SOLAS , 1960 and 1974 International Convention on Load Lines LL , 1966 Special Trade Passenger Ships Agreement STP , 1971 International Regulations for Preventing Collisions at Sea COLREG , 1972 International Convention for Safe Containers CSC , 1972 Convention on the International Maritime Satel lite Organization INMARSAT , 1976 The Torremolinos International Convention for the Safety of Fishing Vessels SFV , 1977 International Convention on Standards of Training, Certification and Watchkeeping for Seafarers STCW , 1978 International Convention on Maritime Search and Rescue SAR , 1979 International Convention on Standards of Training, Certification and Watchkeeping for Fishing Vessel Personnel STCW F , 1995 International Convention for the Prevention of Pol lution of the Sea by Oil OILPOL , 1954 replaced by the MARPOL Convention Convention on the Prevention of Marine Pollution by Dumping of Wastes and Other Matter LDC , 1972 International Convention for the Prevention of Pol lution from Ships, 1973, as modified by the Proto col of 1978 relating thereto MARPOL 73 78 International Convention Relating to Intervention on the High Seas in Cases of Oil Pollution Casual ties INTERVENTION , 1969 International Convention on Oil Pollution Prepar edness, Response and Co operation OPRC , 1990 International Convention on Civil Liability for Oil Pollution Damage CLC , 1969 International Convention on the Establishment of an International Fund for Compensation for Oil Pollution Damage FUND , 1971 Convention relating to Civil Liability in the Field of Maritime Carriage of Nuclear Materials NUCLEAR , 1971 Athens Convention relating to the Carriage of Pas sengers and their Luggage by Sea PAL , 1974 Convention on Limitation of Liability for Maritime Claims LLMC , 1976 International Convention on Liability and Com pensation for Damage in connection with the Car riage of Hazardous and Noxious Substances by Sea HNS , 1996 Convention on Facilitation of International Mari time Traffic FAL , 1965 International Convention on Tonnage Measurement of Ships TONNAGE , 1969 Convention for the Suppression of Unlawful Acts against the Safety of Maritime Navigation SUA , 1988 Protocol for the Suppression of Unlawful Acts against the Safety of Fixed Platforms Located on the Continental Shelf SUAPROT , 1988 International Convention on Salvage SALVAGE , 1989 European Charter on Environment and Health 1989 Helsinki Declaration on Environment and Health 1994 Environmental Health Action Plan for Europe 1994 HEALTH21 Health for All Policy Framework for the European Region for the 21st Century 1998 1998 Guidelines for drinking water quality 1993 Community noise guidelines forthcoming Guidelines for safe recreational water environments forthcoming The Athens Declaration for Healthy Cities 1998 Resolution on Healthy Cities Strengthening ac tion for health for all at local and city levels in the European Region of WHO EUR RC48 R3 Communication from the Commission: The fu ture development of the common transport policy A global approach to the construction of a Com munity framework for sustainable mobility, Sup plement 3 93 to the Bulletin of the European Communities, drawn up on the basis of COM 1992 494 final Towards sustainability A European Community programme of policy and action in relation to the environment and sustainable development, OJ No. C138 5, 17 May 1993 Community Action Programme for Accessible Public Transport Report from the Commission to the Council concerning the actions to be taken in the Community regarding the accessibility of transport to persons with reduced mobility, 26 No vember 1993 The citizens network Fulfilling the potential of public passenger transport in Europe, European Commission Green Paper, 1996 Communication from the Commission: Promot ing road safety in the European Union: the pro gramme for 19972001, COM 1997 131 final of 9 April 1997 Communication from the Commission: A strat egy for integrating environment into EU policies, Cardiff, June 1998, COM 1998 333 final of 27 May 1998 Conclusions of the European Council, Cardiff, June 1998 Conclusions of the joint Transport and Environment Council, Luxembourg, June 1998 Communication from the Commission: The com mon transport policy Sustainable mobility: Per spectives for the future, COM 1998 333 final of 25 May 1998 Relevant regulations concerning safety and environ mental matters in the UIC Code Manual of ECAC Recommendations and Resolu tions relating to Facilitation and Security Matters, ECAC Doc. No. 30 7th ed. , April 1998 Section 5: Facilitation of the transport of persons with re duced mobility Recommendation on the design and operation of passenger ships to respond to elderly and disabled persons needs, 24 June 1996 No. 94 6On the Promotion of Combined Trans port No. 97 6On the Development of Combined Transport No. 97 3Comprehensive Resolution on Trans port for People with Mobility Handi caps No. 66On Transport and the Environment No. 98 1On the Policy Approach to Internalis ing the External Costs of Transport No. 34On Pedestrian Safety 1975 No. 39On the Road Safety of Children and Young People No. 43On Monitoring Compliance with Speed Limits and Traffic Lights No. 44On Making Cycling Safer No. 50On Road Safety of Children No. 90 4On Access to Buses, Trains and Coaches for People with Mobility Handicaps No. 91 3On the Improvement of Road Safety for the Elderly No. 92 3On Decentralised Road Safety Policies No. 93 5On Drink as a Factor in Road Accidents No. 97 5On Cyclists No. 68On Transport for People with Mobil ity Handicaps No. 91 8On Information and Communication No. 94 2On Access to Taxis for People with Re duced Mobility Comprehensive Resolution on Persons with Mobil ity Handicaps, 21 April 1997 Declaration on Vulnerable Transport Users, 21 April 1997 Resolution on Phasing Out Lead in Petrol forth coming Vancouver Principles for Sustainable Transport 1996 The Vienna Declaration and the Programme of Joint Action adopted by the UN ECE Regional Confer ence on Transport and the Environment at the Min isterial Level, November 1997 rhus Declaration on the Phase out of Added Lead in Petrol, adopted on 24 June 1998 in rhus Den mark Agenda 21: Programme of Action for Sustainable Development, United Nations Conference on En vironment and Development UNCED 1992 HABITAT Agenda on Human Settlements 1996 Ministerial Declaration of the Central European Initiative CEI : Towards sustainable Transport in the CEI Countries 1997 UNEP International Declaration on Cleaner Pro duction 1998 Charter of European Cities and Towns Towards Sustainability The lborg Charter 1994 Transport activities shall be managed so that the needs of the present generation are met without compromising the ability of future genera tions to meet their own needs. Action to prevent, con trol or reduce the release of transport emissions harmful to health and the environment should not be postponed on the ground that scientific research has not fully proved a causal link between those emissions at which such action is aimed, on the one hand, and their potentially harmful impact on health and the environment, on the other. This entails reducing air, soil and water pollution, accident risks and noise, greenhouse gases emission and damaging of forests below harmful levels, and assessing and managing the risks from hazardous substances, technologies or processes so that their harmful effects are minimized, including not bring ing them into use or phasing them out as soon as possible. This covers the physical, mental and social wellbeing and safety of all people, paying particular attention to those groups of the population who are more likely to be harmed by the effects of transport, such as children and women, the elderly, the disabled and those with impaired hearing, as well as to the population most exposed to transport risks such as those living in urban or sensitive areas, where pollution and noise are intensified due to geographic and topographic circumstances. , by virtue of which the costs of pollution prevention, control and reduction should be borne by the polluter. The full health and environmental costs of transport should be borne by the polluters as far as possible. Environment and health requirements shall be properly integrated into trans port, water and land use policies, infrastructure programmes and investments and other transport related planning activities. Environment and health authorities shall be fully involved in all levels of de cision making, and international cooperation on sustainable and health promoting transport shall be encouraged. The health benefits from transport shall be accessible to all, and the disbenefits shall not fall disproportionately on certain groups of the popula tion, in particular children and women, the dis abled and the socially excluded, certain generations or certain regions. Public access to the relevant information on transport related health and environmental risks and broad dissemi nation of this information shall be ensured at an early stage. The public, NGOs, the private sector, municipalities and regions shall be encouraged to participate in taking environment and health related transport decisions. Decisions and actions to manage ac tivities relevant for transport should be taken at the adequate administrative level and as closely as pos sible to the citizens. Efficient use of transport should be pro moted through economic instruments and aware ness building measures. Reduce the need for motorized transport and car dependency, by orienting land use policies and ur ban and regional planning towards shortening trans port distances and providing easier access to health promoting modes of transport, on the one hand, and towards making fuller use of existing ca pacities, on the other. Shift transport volumes to environmentally sound and health promoting transport, by promoting those modes which are linked with high levels of physical activity, can be the safest, cause the lowest specific emissions and noise, and best conserve resources, and in parallel by discouraging the use of modes of transport and technologies which damage health and the environment. Implement the best available technologies and best environmental and health standards, best planning methods and best practices for transport involving all relevant sectors and scientific approaches, e.g. transport and land use planners, technologists, and environmental, public health and communication experts. Apply health and environmental indicators and impact assessments as a basis for transport, water and land use policies, urban and regional develop ment planning, location decisions, infrastructure planning and investment programmes, with the full involvement of environmental and health authori ties. Resolve market distortions by: internalizing trans port related environmental and health costs and benefits; bringing the costs of transport into rela tion with the mileage travelled; implementing eco nomic instruments to stimulate health promoting mobility behaviour and shifts in use of different modes of transport. Raise awareness of health promoting transport and mobility, consumption and production patterns, communicating the benefits of healthy transport through public relations activities and information campaigns and the dissemination of information on transport related health impacts to the public, im portant target groups and stakeholders. Develop and apply innovative methodologies such as backcasting and impact assessment, as well as indicators and other tools for monitoring the health and environmental impacts of transport, thus pro viding objective guidance to policy makers and stakeholders. Establish partnerships at international, national, subnational and local levels between governmental and intergovernmental bodies, the public, environ mental, health and transport NGOs, industry, the private sector, etc., ensuring that synergistic actions are taken and that measures at one level do not in crease transport related adverse effects at other lev els. In particular, intensify cooperation with economies in transition, with the aim of fostering good practices related to health promoting trans port. Launch and promote pilot projects and research programmes on transport sustainable for health and the environment. Provide broad public information on the environ mental health impacts of transport and promote public participation in decision making processes with relevance to transport, land use and infrastruc ture policies and planning. As soon as possible, and at the latest by the year 2004, each Member State will define national quan titative or, where technically not feasible, qualita tive health targets to make progress towards attainment of the regional health targets set out be low. When defining these targets, Member States will take due account of their existing international obligations and relevant ongoing international work in other fora. Member States will also take account of cost effectiveness and practicability. To reduce emissions of and human exposure to air pollutants from transport, as a contribution to achieving levels safe for human health, in compli ance with WHOs . f To reduce as much as possible transport emis sions of and human exposure to air pollutants identified in WHOs as having no safe limits. These include particles, identified hazardous volatile organic com pounds VOCs like benzene, and persistent organic pollutants such as polyaromatic hy drocarbons, dioxins, furans and polychlorin ated biphenyls. g To reduce emissions of and human exposure to CO, NO 2 and SO 2 where transport is a major contributor. h To lower ambient ozone concentrations by re ducing emissions of VOCs and NO X from transport. To reduce exposure to fine and ultrafine particles from transport by setting targets that take into ac count recommendations to be developed by WHO regarding the number, mass, size, surface area and composition of these particles. To reduce human exposure to transport related lead emissions by phasing out leaded petrol, in line with the rhus Declaration. Without delay, to strive to reduce the rate of death and serious injuries from transport, in particular road traffic accidents, to match or improve on existing best performance in the European Region. Mem ber States should set demanding intermediate quan titative targets to help attain this goal. Without delay, to strive to reduce rates of death and serious injuries from transport, in particular road traffic accidents among pedestrians and cyclists, while at the same time encouraging an increase in the amount of walking and cycling. To contribute towards the reduction of several com mon and serious diseases notably cardiovascular dis eases and functional deterioration through substantial increases in regular physical exercise and through physically active modes of transport, nota bly walking and cycling. To create supportive environmental conditions, set tlement patterns, land use planning conditions and public transport infrastructures and services that permit and stimulate a substantial increase in the number of short trips undertaken by these physi cally active modes of transport. To improve human health and wellbeing by reduc ing exposure to noise from transport, by: i introducing targets that take into account rec ommendations contained in WHO guidelines on noise 1980, 1993, 1999 , including con cern for specific environments where quiet ness should prevail residential areas, schools, hospitals , environments where the noise of transport activities should be reduced areas within range of airports, highways, railways, terminals, petrol stations and sensitive time periods nights, evenings, weekends ; j reversing the trend towards an overall increase in noise pollution through a combination of noise emission and noise immission control measures; k keeping night time sound levels in residential areas within WHO recommended night time values and, where these values are currently exceeded, striving to reduce them to recom mended sound levels; l protecting existing quiet parkland and con servation areas and promoting quietness in such areas, by keeping down the ratio of noisy transport activities relative to background sound levels in these areas. The need for a session on transport at the Third Ministerial Conference on Environment and Health was identified in a questionnaire survey by WHO in 1996 of Member States in its European Region. The European Environment and Health Commit tee endorsed that need and proposed the develop ment of a charter; Austria agreed to act as lead country. The text of the charter was negotiated at a series of intergovernmental meetings attended by representatives of ministries of transport, the envi ronment and health of Member States in WHOs European Region, international organizations, the European Commission and nongovernmental or ganizations. The drafts discussed at those meetings were prepared by drafting groups established at the first intergovernmental meeting. WHO gratefully acknowledges the support provided by the governments of Austria, Denmark and Malta, the European Environment Agency and the United Nations Environment Programme. Transport eases access to jobs, education, markets, leisure and other services, and has a key role in the economy. Nevertheless, road users generate excessive costs to themselves, other individuals and society through noise, pollution and accidents in the form of illness, injuries, deaths and damage to mental health and social relationships. The continuing ex pansion of motorized transport in Europe today raises crucial questions about the efficiency and the environmental, health and social implications of land use and transport policies. Too often, such policies disregard these implications. The challenge is to promote healthy and sustainable transport alternatives to prevent the negative effects of transport systems on human health. Meeting this challenge requires com mitment and action from governments. The Member States in the WHO European Region expressed their commitment by adopting the Charter on Transport, Environment and Health the WHO Third Ministerial Conference on Environment and Health, in London in June 1999. This book summarizes the key facts on which countries based their decision. Developed from a document prepared for the London Conference, it summarizes the latest scientific evidence on the impact of transport generated air pollution, noise and accidents on behav iour and physical and mental health. The book also highlights the considerable potential health benefits from non motorized forms of transport, such as cycling and walking. This book can alert policy analysts, decision makers and politicians to current knowledge, and point the way to action for sustainable transport. It calls for policies that require the creators of transport related costs to pay for them, and take proper account of environment and health implications in decisions on transport infrastructure and urban development. These and other steps are needed if Europe is to reduce ill health and realize the potential for transport to serve societys needs and promote peoples health. #font 33 "HelMed 355 0" World Health Organization Regional Office for Europe Copenhagen #font 5 "Frutiger Black 338 0" Transport, environment and health Transport, environment and health WHO Regional Publications, European Series, No. 89 T R A N S P O R T , E N V I R O N M E N T A N D H E A L T H Transport, environmen and health Transport, environment and health WHO Regional Publications, European Series, No. 89 T R A N S P O R T , E N V I R O N M E N T A N D H E A L T H Contents

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