Executive Summary Public Health and the EU: an overview Written by Mariann Skar March 2007
Introduction This is the Executive Summary of the book Public Health and the EU: an overview. While the full publication is currently only available in English and can be downloaded for free from the website of the European Public Health Alliance (http://www.epha.org/), this Executive Summary has been published in all the EU languages and printed with the financial support of the European Commission and private Foundations. Public Health and the EU: an overview was first published in 1995 as a compilation of policy briefings prepared by EPHA. A decade later, we are happy to present an updated version, referencing the latest developments in EU public policies, such as the draft European Constitution, the new Public Health Programme and the impact of the EU enlargement on health policies. EPHA s mission is to promote and protect the health of all people living in Europe and to advocate greater participation of citizens in health-related policy making at European level. EPHA has published this book to provide an introduction to the wide range of European Union (EU) activities that affect public health. It aims to inform local, national and European organisations about the opportunities and challenges that the EU poses to public health. We see this as a precondition for broadening and strengthening the involvement and commitment of civil society in policy making. More importantly, it also highlights the crucial role played by non-governmental organisations, in bridging the gap between citizens and decision-makers, and acting as a counter weight to vested interests. This overview touches upon the current activities of the EU (as of 2007) in the following areas: health status in the European Union, including the impact of enlargement; the main instruments available at an EU level to influence public health issues; the impact of other EU policy areas (internal market, agriculture, environment, research, health and safety at work, etc.) on public health; the relationship between patient mobility and health care developments and how this may lead to closer EU cooperation and coordination; the exchange of data on health and the development of good practice; the importance of health determinants like nutrition, physical activity, alcohol, tobacco, drugs, mental health and injuries; 1
the impact of communicable diseases on the EU agenda and how recent health scares such as SARS and avian influenza have emphasised the need for EU action; the importance of pharmaceuticals and medicines to European citizens and the economy, and how considerations regarding cost, competition and safety makes an impact on overall public health policies. Public Health The publication includes a brief introduction to different concepts of public health, briefly explaining the origin of the public health movement and its main achievements. People everywhere, throughout their lives, are exposed to an almost limitless array of risks to their health, whether in the shape of communicable or noncommunicable diseases, injuries, consumer products, violence or natural catastrophes. No risks occur in isolation: many have their roots in complex chains of events spanning long periods of time. 1 In essence public health is about creating the conditions for a healthy society. Public health can therefore be defined as the objective and measurable health of a population, the life expectancy of its individual members and the extent to which they are free from disease. But this is a rather narrow definition. Vaccination and better screening has had an impact on public health, but policies in other areas, like better housing, clean water, sanitation systems, safe food, education etc., have made an even bigger impact. A broader definition of public health is reflected in Winslow s classic definition from 1920: Public health is the science and art of preventing disease, prolonging life and promoting physical health and efficiency through organised community efforts for the sanitation of the environment, the control of community infections, the education of the individual in principles of personal hygiene, the organisation of medical and nursing service for the early diagnosis and preventive treatment of disease, and the development of social machinery which will ensure to every individual in the community a standard of living adequate for the maintenance of health 2. The definition above draws in important issues like the prevention of diseases and a focus on the overall standard of living and quality of life; key aspects of current public health policies, including the approach adopted at EU level. In addition, health is also a human right, as stated in the Universal Declaration of Human Rights 3. 2
Public health is far more than basic medical care. Public health, and not only investment in basic medical care, should be the core business of every government in order to improve and promote the health and welfare of its citizens. Health Status in Europe The book Health and the EU: an overview then proceeds with a chapter on the health status of the European population. People in the European Union are living longer and in general enjoying better health than ever before 4. Life expectancy in Western Europe has increased consistently since the 1950s by around 2.5 years each decade. Life expectancy in EU-25 varies from 66-78 years (a gap of 12 years) for men and 76-84 years (a gap of 8 years) for women. The difference between EU countries is wider for healthylife expectancy than for life expectancy. Healthy-life expectancy ranges from 57-75 years (18 years) for women and from 54-71 years (17 years) for men 5. Most predictions assume that this improvement in health will continue. But, lifestyle-related diseases are increasing the risk of life expectancy levelling off. Risk factors such as smoking, obesity, lack of physical activity, high consumption of alcohol, injuries and accidents cause premature death and chronic disease. There is a clear connection between diet, lifestyle and health 6. Non-communicable diseases contribute to over 87%, of the EU s total disease burden 7. Mental health disorders account for 27% of these. In 1999, mental disorders were responsible for more than 40% of disability pensions in Finland and 25% in Portugal. Cardiovascular diseases are currently the biggest single cause of death in the EU 8. They account for around 40% of deaths in both sexes. It is also a major cause of ill health in Europe. Obesity and type-2 diabetes are showing worrying trends, not only because they are affecting a larger population, but also because they have started to appear earlier in life. In the European Union, in 2000, a total of 158 million days work was lost, corresponding to an average of 20 days for every accident 9. In addition, communicable diseases and pandemics can spread more rapidly than ever across national borders because of high mobility. Fortunately, the leading causes of premature death are largely preventable, as their main risk factors are behavioural and can be influenced by effective use of well-known and feasible public health interventions. But, most risks cluster themselves around the poor 10. The above snapshot, explained in more detail in the full publication, shows a Europe full of contrasts. We can observe remarkable improvements in public health over previous decades, significantly improving the life quality of large groups of the population. There are still, however, large differences between and within countries. The potential gains remaining for an efficient public health policy are substantial. 3
The Emergence of an Independent European Health Policy The new version of the book Health in the EU: an overview recognises that health issues are moving up the European political agenda. Article 152 of the Treaty of the European Communities states that a high level of human health protection shall be ensured in the definition and implementation of all Community policies and activities. Today health has emerged not only as a separate and clearly defined policy area but also as an important aspect of other policy areas, for example in agriculture, environment, employment, competition, consumer protection etc. But health care is still, in principle, a sector of national rather than EU competence Community action in the field of public health shall fully respect the responsibilities of Member States for the organisation and delivery of health services and medical care. 11 But as cross-border health threats evolve in a growing Union, the EU plays an increasingly important role in promoting and co-ordinating health care solutions for all the Union s citizens, concentrating its focus on disease prevention, overall preparedness and rapid response to potential dangers. As in any other policy area, European public health policies are developed in the context of shared responsibilities between the Council, the European Parliament and the Commission. The following is a summary of the division of responsibilities and influence of the European Institutions, as described in the full publication: The Council of the European Union is the main EU decision-making body. It represents the EU s Member States, and therefore, is composed of one representative of each EU national government. The acts of the Council can take the form of legally binding regulations, directives, proposals for voluntary common actions, common positions, recommendations, conclusions or opinions. The European Parliament is the European body that directly represents the people of the Member States. It expresses the democratic will of the Unions citizens and represents their interests in discussions with other EU institutions. The European Parliament has three fundamental powers: legislative power, budgetary power and supervisory power. The European Commission is designed to be a politically independent institution that represents and uphold the interests of the EU as a whole. It is the driving force within the EU s institutional system; it has the right to make proposals to the Council and Parliament. In the public health area, this structure is reflected in the following arrangements: the European Commission s Directorate General for Health and Consumer Protection (DG SANCO) was established in 1999. Its main office is in Brussels, but the public health directorate is divided between Brussels and Luxembourg. Around 700 staff work in the Directorate, of which, 120 are responsible for public 4
health. Other directorates general cover health matters within their jurisdiction (described in detail in the full publication). The overall mission for DG SANCO is: Together with the Member States, the European Union aims to protect and promote the health of its citizens. This protection and promotion task has been interpreted in different ways; the main forms of governance currently used are the following: - Legislation and regulation - the legal competence on public health was strengthened under article 152 of the Treaty of Amsterdam. The EU has a limited mandate to adopt public health policies. Member States still adopt measures at a national level to regulate the organisation and delivery of health services, although the EU has a specific right to legislate on blood, organs and tissues (safety and quality of blood, blood derivates, human tissues and human cells used in medical treatments). - Self-regulation and voluntary cooperation (Open Method of Coordination) - there has been a shift away from legally binding instruments (i.e. regulations and directives) towards alternative regulatory methods, such as co-regulation and self-regulation by the social and economic actors concerned. This is expected to reduce costs and increase efficiency. Co-regulation and voluntary self-regulation can take many forms like voluntary agreements, codes of conduct, charters, guidelines, harmonised standards etc. This approach - in some cases referred to as the Open Method of Co-ordination (OMC) - is becoming increasingly prevalent as a method of governance in the European Union. In contrast to the traditional, legalistic approach, it aims at co-ordination rather than harmonisation of national policies. It commits Member States to work together towards shared goals while respecting legitimate national diversity. - EU financing arrangements, like the Community Action Programme for Public Health 2003-2008 12 (with a budget of euro 312 million) and EU initiated information campaigns like Help for a life without tobacco can be seen as supportive to these legal and voluntary approaches. The full publication recognises that the EU should not duplicate Member States efforts but provide added value by concentrating on activities such as monitoring EU wide health statistics, sharing good practices among Member States and providing forums for public dialogue and information exchange. Health in Other EU Policy Areas The EU has a range of public policies that affect health, notably internal market, agriculture, environment, research, consumer protection, health and safety at work etc. The EU s competences on health are rather limited; therefore it is crucial to use all the tools available in other policy areas to improve the health and well-being in the population. The following are a summary of the public 5
policies that have an impact on health, more detail can be found in the full publication. Agricultural policy - Rural areas cover 90% of the EU s territory and are home to approximately 50% of its population. The common agricultural policy (CAP) is a system of support for farmers intended to replace national support schemes to ensure that a product is produced on an equal footing across Member States. CAP has been criticised for making inefficient use of subsidies; spending 50% of the EU s budget and having a negative public health effect by subsidising tobacco farming, alcohol production as well as initiating the destruction of one million tonnes of fruit and vegetables each year. Its negative impact on agriculture in developing countries has also been heavily criticised 13. The financial weight of the CAP in overall EU policies until now is unquestionable and illustrates a number of dilemmas in public health policies and their relevance to economic objectives. As lifestyle related diseases increase, the impact of the CAP has to be carefully assessed. Health and environment - Health is an important part of EU s environmental policy. Key areas of action are outdoor and indoor air pollution, noise, indoor environment and housing conditions, water policies, electromagnetic fields, radiation and chemical exposure. The impact of these factors are associated with numerous health problems including hearing problems, sleeping disorders, stress leading to hypertension and other circulatory diseases, skin and other cancers, respiratory diseases, and birth defects. The interaction between environment and health is far more intimate and complex than is commonly appreciated 14. Research - Research done at EU level has been criticised for being too limited, fragmented and lacking clear focus. To tackle this problem the Commission, in 2000, proposed the creation of the European research area (ERA) 15. EU governments have committed themselves to increase the proportion of gross domestic product invested in research by the private and public sector from the 2000 level of 1.9% to 3% by 2010. The 7th Framework Research Programme (FP7) 16 has a significantly increased budget - 73 billion to be spent over seven years through four key programmes: co-operation, ideas, people and capacities. Health is now one of the nine themes covered in all of these four programmes. Development aid and health; the global perspective - All the worlds countries and development institutions have - through the United Nations - agreed to eight Millennium Development Goals. These goals cover a wide range of issues like halving extreme poverty, halting the spread of HIV/AIDS and providing universal primary education. Developmental aid represents an important and visible part of EU spending on global health (The EU is the main global contributor in this field, providing about 55% of all aid and 65% of grant aid, even though, the EU still spends less on aid than it has pledged to spend). This picture has, however, also to be balanced with the impact of other policies, notably the CAP and internal market, on global health. 6
Pressure Towards European Healthcare Solutions - Patient Mobility and Health Care Developments Health and the EU: an overview also includes a chapter on the provision of health care. Although this is a national responsibility. Due to a number of reasons the health care systems of Europe are becoming more interconnected. Firstly, every EU citizen has the right to work and live in another member state without being discriminated against on grounds of nationality. For health care professionals, this general right is supported through a set of regulations to ensure the mutual recognition of qualifications. The following mechanisms, put in place by Directive 2005/36/EC 16, exist: Harmonisation of training requirements allowing for automatic recognition of professional qualifications (covering doctors, nurses, dentists, midwives, veterinary surgeons, pharmacists and architects) 18. A general system of recognition applying to all other professions. This system outlines the basic rights enjoyed by citizens in the area of professional mobility and specifies the obligations of Member States 19. The sectoral directives for traditional health care professionals have existed since the mid-1970s. Other health care providers have had a less transparent system for recognition of qualifications, (like professions belonging to the complementary and alternative medicines). One of the aims of the 2005 directive was to make recognition of qualifications simpler and more transparent. Secondly, patients are crossing borders in search of better treatment. Patients have the option of obtaining treatment abroad under the Community Regulation 1408/71. Two landmark rulings by the European Court of Justice 20 in May 1998 have implications on the organisation of the healthcare systems. The European Court of Justice has confirmed that citizens are free to seek healthcare in another member state. They can also be reimbursed under certain conditions. Furthermore, according to Regulation 1408/71, when temporarily staying in another member state than your own for travel, study, a posting or seeking employment and if you happen to need healthcare, it will de delivered on the same basis as to people insured in that country. After June 1st 2004, you can show this entitlement using the European Health Insurance Card, which replaced the previous paper forms, in particular the E111 (COM 2004). Thirdly, patient mobility has consequences for health services and medical care both in the country where the patient is insured and the country where care is provided. The Commission is developing a community framework for safe, high quality and efficient health services, by reinforcing co-operation between Member States and providing certainty in the application of community law to health services and healthcare. 7
A Precondition for EU Health Policies - Health Information Health information is important in order to make comparisons between Member States or regions and thus to inform and direct health policies at national and European level. Up to date, high quality information on health status is a prerequisite for the effective development of public health policies. The European Commission aims to produce a set of health indicators; providing concise and comparable information on health and health-related behaviour of the population. The work on health indicators is co-ordinated through advisory working parties responsible for different elements of what will become a health monitoring system. Working parties have been created in the following fields: morbidity and mortality, accidents and injuries, mental health, lifestyle and other health determinants, health and environment, health systems and European Community health indicators. This activity should improve the quality and comparability of data, to facilitate access and improve analysis of available information. The final objective is thus to develop a European Union system of health information and knowledge which is fully accessible to European experts and the general public. Providing Focus for EU Health Policies - Health Determinants Seven risk factors all of them non-communicable diseases - are responsible for most of the disease burden in the World Health Organisation s European Region. These are: high blood pressure, tobacco use, harmful and hazardous alcohol use, high cholesterol, being overweight, low fruit and vegetable intake and physical inactivity. Non-communicable diseases are to a great extent preventable. Up to 80% of instances of coronary heart disease and up to 90% of type-2 diabetes could be avoided by lifestyle changes. Healthy eating, maintaining normal weight and increased physical activity can, for example, reduce cancer by one third. The following determinants are the most important, and the concrete actions of the EU institutions on these areas are detailed in the full publication. Nutrition and Physical Activity - The relationship between diet, lifestyle and health has been scientifically established, in particular regarding the role of diet and lifestyle as determinants of chronic non-communicable diseases such as obesity, cardiovascular disease, cancer, type-2 diabetes, hypertension and osteoporosis 21. The European Commission has taken several steps to address these public health challenges; Council Conclusions have been adopted; examples here are healthy lifestyles in 2003, promoting heart health in 2004, and on diabetes in 2006. 8
The European Network on Nutrition and Physical Activity was established in 2003 and is composed of experts nominated by the Member States. A coherent and comprehensive community strategy on nutrition, physical activity and obesity, is expected by June 2007. It builds on the consultation of the green paper: Promoting healthy diets and physical activity: a European dimension for the prevention of overweight, obesity and chronic diseases. It is expected to include the mainstreaming of nutrition and physical activity into all relevant policies at local, regional, national and European levels and the creation of the necessary supporting environments. As an experiment the Commission services launched a forum, called Diet, Physical Activity and Health a European platform for action, based on the experience of the obesity round table. Relevant players at European level (retailers, food processors, the catering industry, the advertising business, consumer and health NGOs, the medical professions etc.) have met regularly since 2005, the purpose being to identify and agree on concrete actions that could help to halt or even reverse current obesity trends. An important purpose is also to make sure that potential partners know all obesity-related initiatives, to provide more coherent policies and actions. Food safety is also a priority for the EU. The European Food Safety Agency (EFSA) was established in 1996 to deal with health threats from food supply, and its mandate has now been extended by the European Commission to include nutrition. Alcohol Alcohol consumption increases the risk for more than 60 different types of diseases and conditions. The negative social impact of alcohol is also significant, ranging from general social nuisances to domestic violence, increasing fire incidents, drownings and motor vehicle accidents, child abuse, crime and homicide. Some 55 million adults are estimated to drink to harmful levels in the EU, of these are 23 million considered to be addicted. Some of the European Union directives that have so far been adopted relate to: alcohol taxation, a Recommendation on the drinking of alcohol by young people (2001) and the Television Without Frontiers Directive (Directive 89/552/EEC), which foresees restrictions on alcohol advertising, In October 2006, the European Commission adopted a comprehensive Alcohol Strategy to support Member States in reducing alcohol related harm in Europe 22. The European Commission has set up an Alcohol and Health Forum by June 2007, which will bring together experts from different stakeholder organisations, including NGOs, the drinks industry and retailers. Representatives from Member States and other EU institutions and agencies also meet in a separate consultative committee. The overall objective of this forum is to support, provide input for and monitor the implementation of the strategy outlined in the communication. Tobacco - Preventing smoking has been on the agenda for health professionals, politicians, NGOs, Member States and the European Commission for years. Still 9
approximately one third of the adult population in Europe smokes. It is estimated that tobacco kills some 650,000 Europeans every year, i.e. one in seven of all deaths across the EU. Smoking harms nearly every organ in the human body, causing a broad range of diseases. Half of all regular smokers will be killed by their smoking and those that die in middle age have, on average, their life expectancy reduced by 22 years, with a larger proportion of that shortened life span being spent in ill health. Over 13 million more suffer from serious chronic disease as a result of their smoking. In addition passive smoking kills more than 79,000 adults each year in EU-25. 23 Efforts to reduce tobacco consumption in the EU have included recommendations and legislation, such as: Public places and the workplace - In 1989 the EU adopted a Resolution banning smoking in public places and on all forms of public transport. Tobacco Product Regulation - In 2001, a Directive regulating tobacco products became law. European Union Directive on Tobacco Advertising In 2003 a Directive to ban tobacco advertising was enacted, it now covers advertising that crosses national borders and sponsorship of sport. Framework Convention on Tobacco Control - In 2004, the EU Council approved the World Health Organisation s Framework Convention on Tobacco Control (FCTC) 24. Health warnings were increased to at least 30% of the front and 40% of the back surfaces of tobacco packaging. Taxation - Tobacco is a very heavily taxed product in most Member States. The European Commission launched a public consultation on the best way to promote smoke-free environments during the spring of 2007 with its Green Paper Towards a Europe free from tobacco smoke: policy options at EU level 25. Drug consumption - Drug consumption particularly among young people, is at historically high levels. There are up to two million problem drug users in the EU today 26. National drug laws increasingly tend to emphasise the distinction between offences involving drug possession for personal use and those involving trafficking and supply. Generally, there is a shift towards increased penalties for the latter. This development is in line with a greater overall emphasis across Europe on widening the opportunities for drug treatment and on giving more attention to interventions that divert those with drug problems away from the criminal justice system, towards treatment and rehabilitation options. The Commission sees illegal drug use - and to a certain extent also legal drug abuse as a major public health issue. Action has been concentrated on prevention through education and awareness raising, but also including risk/harm reduction and treatment. The European approach to tackling the Union s drug problems has been developed through the EU s Drug Strategies 10
(2005 2012) and Action Plans (2005 2008). This model involves achieving a balance between prevention, education and treatment on the one hand, and the enforcement of laws against drug manufacturing and trafficking on the other. Mental health - According to the World Health Organisation, no single official definition of mental health exists. Cultural differences and competing professional theories all affect how mental health is defined. Mental health is an everyday issue that affects individuals, families, schools and the workplace. The issue is critical for Europe because mental health issues account for almost 20% of the burden of disease 27. However, the provision of care is often inadequate and does not give the help needed, even when mental health problems are severe. In 2005, health ministers in Europe committed, for the first time, to mainstream action on mental health as part of their public health policies 28. In 2006, the European Commission launched an open consultation based on the Green paper Promoting the Mental Health of the Population. Towards a Strategy on Mental health for the European Union 29. It received a great many (237) responses 30. The Commission services are now drafting a Communication setting out a strategy on mental health. It is scheduled to be adopted during spring 2007. Injury prevention - Injuries are a leading cause of death and disability among the European population 31. The risk of death and severe injury is particularly high in such diverse areas as home and leisure road traffic, workplace, and in connection with consumer products and services. Unintentional and intentional injuries are estimated to be the main cause of death and chronic disability in children, youth and adults till the age of 45 years, leading to an enormous loss of life years in good health and employment production years. Among people over 65 years of age, injuries are a major cause of death and disability and are often the trigger for a fatal deterioration in their health. The European Commission has taken several initiatives to initiate action and be able to reduce the frequency of unintentional and intentional deaths and injuries by working collaboratively on this cross cutting issue with a number of DGs in the areas of transport, workplace, mental health, violence, alcohol, and child health. More than 80 projects specific to advance injury prevention have been undertaken in the period from 1999 2002 32. However, there is still scope for more effective action, in particular by adopting evidenced good practice proven to reduce injuries that has been published. The European Commission has also adopted in June 2006 Commission Communication on action for a Safer Europe 33 and the Proposal for a Council Recommendation on the prevention of injuries and the promotion of safety pending approval May 2007 34. 11
Providing Focus for EU Health Policies - Communicable Diseases Communicable diseases such as HIV/AIDS, tuberculosis, measles and influenza, represent a serious risk to human health, contributing to about one third of all deaths occurring globally. Communicable diseases do not respect national frontiers and can spread rapidly particularly in today s interconnected world. Furthermore, new diseases emerge and others develop drug-resistant forms such as multi-drug resistant tuberculosis, and methicillin resistant staphylococcus aureus. In order to be prepared for these threats, the Commission collaborates closely with the Member States in this field. Generic preparedness plans have been introduced by the Commission to address different types of health threats. Specific plans have been issued both at national and at the community level to address the issues of pandemic influenza, SARS, smallpox or bio-terrorism. The European Centre for Disease Prevention and Control (ECDC) is in charge of providing scientific advice and risk assessment concerning messages received through the Early Warning Response System (EWRS) 35. The full publication provides more information about this subject under a dedicated chapter. Providing Focus for EU Health Policies Medicinal Products and Therapies Comprehensive regulations on medicines have been developed in all the EU Member States throughout this century, in particular from the 1960s onwards. The growing complexity and lack of compatibility of national regulations has led to attempts at EU level to harmonise regulatory systems. All medicines currently available in Europe have to meet standards of safety, quality and efficiency as laid down in EU legislation (described in more detail in the full publication). However, there are great differences in the extent and type of controls on complementary medicines throughout the Member States. In 1992, the EU started to take action in this field with Directive 92/73EEC 36 on homeopathic medicinal products and other actions that are detailed in the publication. The European Union is committed to ensure a high level of quality, safety and innovation in the field of pharmaceuticals. In the context of medicines and treatments the key objectives are to guarantee access to medicines at an affordable cost, ensure that medicines are safe and effective and enable citizens to make informed choices. This needs to be balanced by supporting the competitiveness of the pharmaceutical industry. 12
The High Level Pharmaceutical Forum was set up in June 2005 to meet these needs by the Directorates General for Enterprise and Industry, and Health and Consumer Protection 37. The Forum brings together Member States, the pharmaceutical industry, public health and patient groups in a voluntary cooperation process, seeking to balance national and European solutions. Conclusion Good health is a fundamental resource for social and economic development. Higher levels of human development mean that people live longer and enjoy more healthy years of life. A healthy population will reduce the pressure on health and social care systems. A healthy workforce is a precondition for economic growth and prosperity. In today s Europe, with a rapidly ageing population, this is truer than ever before. The publication recognises the remarkable improvements in public health in recent decades, but notes that there are still large differences between population groups, regions and countries. Although health care mainly is a national responsibility, many of the most important threats to health cannot be solved by national public health policies, nor are they restricted by geographical borders. Co-ordinated EU action on public health is increasingly important. Civil society has played an increasingly significant role in shaping and delivering health outcomes at local, regional, national and the European level. Civil society will continue to play a key role in undertaking actions which add value and complement the work done by the EU and Member States to make citizens healthier and safer. The EU has made considerable progress in order to increase dialogue with civil society, opening it up to a multitude of stakeholders from different countries and sectors. But there is still a lot of work to be done, specially building the capacity of civil society to engage in policy making. 13
Notes 1. For more information on risks see The World Health Report 2002 Reducing Risks, Promoting Healthy life, World Health Organization 2002 2. Winslow 1920, p23 in Baggott, Rob Public Health Policy and Politics,Palgrave Macmillan 2000 3. Article 25 of the Universal Declaration of Human Rights adopted and proclaimed by General Assembly Resolution 217 A (111) of 10 December 1948 4. Key data on health, Eurostat 2005 5. Kjaesrud and Siddel, European Commission 2006 6. Diet, Nutrition and the Prevention of Chronic Diseases Report of a Joint WHO/FAO Expert Consultation. 2003 7. Statistics in focus Population and social conditions Theme 3 2/2004 8. Statistics in focus Population and social conditions Theme 3-2/2004 9. Communication from the Commission Improving quality in work: a review of recent progress COM (2003) 26.11.2003 728 final 10. The World Health Report 2002 Reducing Risks, Promoting Healthy life World, Health Organization 11. Article 152 of the Amsterdam Treaty - The competence of the EU to address matters of public health is based on Articles 129 and 152 respectively of the 1993 Maastrich Treaty on European Union and the 1999 Treaty of Amsterdam 12. http://europa.eu.int/comm/health/ph_programme/programme_en.htm 13. For more information see: Public health aspects of EU Common Agricultural Policy developments and recommendations for change in four sectors: Fruit and vegetables, dairy, wine and tobacco by Liselotte Schafer Elinder, National Institute of Public Health, Sweden, 2003 14. European Environmental Agency and WHO 15. For more information see: http://ec.europa.eu/research/era/index_en.html 16. http://europa.eu.int/comm/research/future/index_en.cfm 17. http://ec.europa.eu/internal_market/qualifications/future_en.htm 18. http://ec.europa.eu/internal_market/qualifications/specific-sectors_en.htm 19. http://ec.europa.eu/internal_market/qualifications/general-system_en.htm 20. Case C-158/96 Kohll [1998] ECR I-1931 and Case C-120/95 Decker [1998] ECR I-1831 21. Diet, Nutrition and the Prevention of Chronic Diseases Report of a Joint WHO/FAO Expert Consultation. 2003 22. Communication from the Commission to the Council, the European Parliament, the European Economic and Social Committee and the Committee of the Regions An EU strategy to support Member States in reducing alcohol related harm 24/10/2006. Com (2006) 625 final 23. Green paper Towards a Europe free from tobacco smoke: policy options at EU level. COM (2007) 24. http://www.who.int/tobacco/framework/countrylist/en/ 25. http://www.ec.europa.eu/health/ph_determinants/life_style/tobacco/keydo_tobacco_en.htm 26. 2006 Annual Report on the state of the drugs problem in Europe by the European Monitoring Centre for Drugs and Drug Addiction. http:// annualreport.emcdda.europa.eu 27. Green Paper Improving the mental health of the population. Towards a strategy on mental health for the European Union. European Commission 2006 28. http://www.euro.who.int/mentalhealth2005 29. http://europa.eu.int/comm/health/ph_determinants/life_style/mental_health_en.htm 30. From Responses to the Green Paper: Promoting the Mental Health of the Population. Towards a Strategy on Mental health for the European Union. European Commission 19.12.2006 31. For more information see; http://ec.europa.eu/health/ph_determinants/environment/ipp/ipp_en.htm 32. For more information see; http://ec.europa.eu/health/ph_projects/injury_project_full_listing_en.htm 33. Communication from the Commission to the European Parliament and the Council On Actions for a Safer Europe COM(2006) 328 Final 34. Proposal for a Council Recommendation on the prevention of injury and the promotion of safety COM (2006) 329 Final 35. Commission Decision of 19 March 2002 laying down case definitions for reporting communicable diseases to the Community network under Decision No 2119/98/EC of the European Parliament and of the Council, 2002/253/EC 36. Council Directive 92/73/EEC of 22 September 1992 widening the scope of Directives 65/65EEC and 75/319/EEC on the approximation of provisions laid down by law, regulation or administrative action relating to medicinal products and laying down additional provisions on homeopathic medicinal products, OJ L 297/8 (1992) 37. http://ec.europa.eu/health/ph_overview/other_policies/pharma_forum_en.htm http://ec.europa.eu/enterprise/phabiocom/comp_pf_en.htm 14
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