Indicators are important tools for highlighting problems, identifying trends, and monitoring progress, all of which contribute to effective policy formulation. A complex system for collecting health and environmental data and indicators has been in place in Israel for many years. The Ministry of Environmental Protection (MoEP) published a comprehensive report on environmental indicators in 2010 and an additional report on well-being and sustainability indicators in 2013. The Ministry of Health (MoH) and the Central Bureau of Statistics (CBS) regularly publish data on health and health-promotion indicators, including life expectancy, infant mortality, diabetes prevalence, reported smoking rate, overweight and obesity, and percentage of adults engaging in regular physical activity. In 2012, Israel was chosen by the Organisation for Economic Co-operation and Development (OECD) to be the pioneer in consolidating a set of national indicators on well-being and sustainability.
While extensive health and environmental indicator data are regularly collected and published in Israel, and are being further developed within the framework of the OECD indicators project, environmental health indicators have not been developed in Israel. According to the World Health Organization (WHO), environmental health indicators are needed to:
- monitor trends in the state of the environment, in order to identify potential risks to health;
- monitor trends in health resulting from exposure to environmental risk factors, in order to guide policy;
- compare areas or countries in terms of their environmental health status, so as to target action where it is most needed or to help allocate resources;
- monitor and assess the effects of policies or other interventions on environmental health;
- help raise awareness about environmental health issues across different stake-holder groups; and
- help investigate potential links between environment and health (e.g. as part of epidemiological studies), as a basis for informing health interventions and policy.
Developing environmental health indicators and collecting relevant information require coordination and cooperation among stakeholders, such as: the MoH, the MoEP, the CBS, the Israel Center for Disease Control (ICDC), Health Maintenance Organizations, and NGOs.
Environmental health indicators have been developed by:
- The WHO
- The US Centers for National Environmental Public Health Tracking Network of the Disease Control and Prevention (CDC)
- The European Union Environment and Health Information System (ENHIS).
The WHO framework includes environmental health indicators in 12 areas: socio-demographic context, air pollution, sanitation, hazardous/toxic substances, food safety, radiation, nonoccupational health risks, occupational health risks, shelter, access to safe drinking water, vectorborne disease, and solid waste management. The CDC system includes indicators in 17 areas, while the ENHIS program includes 22 indicators. In 2010, the WHO proposed further development of the ENHIS guidelines so as to enable targeted evaluation of public health policy on reducing adverse health outcomes associated with priority environmental health factors.
Table 1 presents selected environmental health indicators chosen from the list of the WHO, CDC, and ENHIS indicators, with high relevance to environmental health in Israel. Data availability from the MoH, the MoEP, the ICDC, or other sources is indicated.
Table 1: Selected Environmental Health Indicators and Data Availability in Israel
The above table shows that data are available in Israel for numerous environmental health indicators developed by the CDC, WHO and the European Union. However, it is important to note that data are lacking for many environmental health indicators, including ventilation in schools, childhood exposure to lead and mercury, and data on heat stress related hospitalizations and mortality. In addition, there are environmental health indicators not included by the WHO, CDC or European Union that may have relevance for environmental health in Israel, for example, data on organophosphate exposure. Below is a summary of data for selected proposed additional environmental health indicators in Israel (Table 2).
Table 2: Available Data for Additional Environmental Health Indicators in Israel
Data Sources - Health Trends in Israel
- The 1940 Public Health Ordinance requires mandatory reporting for selected diseases and health outcomes, including cancer, birth defects, and selected infectious diseases.
- Data on various diseases including asthma, diabetes, stroke, and cardiovascular disease are available in Israel from national surveys (the Knowledge Attitude and Practice Survey, the Israel National Health Interview Survey, Acute Coronary Syndrome Survey, National Acute Stroke Survey).
- The MoH has established databases on cause of death, emergency department visits, and hospitalizations.
- The Israel Center for Disease Control Diabetes Type 1 Registry includes information on diabetes in children, ages 0-17.
- Data are available on age of menarche from a population-based ongoing survey (in army recruits) from 1986 onwards, and on health problems among adolescents, based on mandatory examination of army candidates since 1967.
- There are national statistics on assisted reproductive technology in Israel beginning in 1990.
Selected Environmental Health Data and Trends
According to the WHO, an estimated 24% of the global disease burden and 23% of all deaths can be attributed to modifiable environmental factors, including diarrhea, lower respiratory infections, injuries and malaria. This chapter presents current data in Israel (and long-term trend data when available) on selected health endpoints associated with exposure to environmental contaminants (including radiation, endocrine disrupting chemicals (EDCs), lead, indoor pollution, ambient air pollution).
Cardiovascular diseases have been associated with exposure to air pollution, exposure to chemicals such as lead, and exposure to environmental tobacco smoke (ETS). According to WHO estimates, exposure to outdoor air pollution accounts for approximately 2% of the global cardiopulmonary disease burden. Cardiovascular disease is the second leading cause of death in Israel in men over 45 and women ages 45–74. In Israeli adults, between 2007 and 2010 10.2% of men were diagnosed with heart disease, compared to 7.1% of women. Rates of cardiovascular-related mortality decreased by 70% in Israel between 1980 and 2011.
Asthma development and exacerbation can be triggered by a variety of indoor and outdoor environmental exposures, including dampness, ETS, and air pollution. In 2008, the prevalence of asthma in children ages 13–15 (based on self-report) was 7.2% (7.2% for Jewish children, 7.0% for Arab children). This rate is slightly higher than that reported in 1997 (7.0% overall) and 2003 (6.4% overall). In adults over age 21, 5.8% reported between 2007–2010 that they were diagnosed with asthma.
Environmental and occupational risk factors have been linked to many types of cancer, primarily lung cancer, stomach cancer, leukemia, and melanoma. This report presents data on selected types of cancer: melanoma, which has been linked to excessive UV exposure; childhood leukemia, which has been linked to exposure to radiation and chemical agents; and testicular and breast cancer, which have been linked to exposure to EDCs. Based on data from the Israel National Cancer Registry of the MoH which includes an estimated 94% of solid tumors and an estimated 85% of non-solid tumors, rates of both invasive and in situ melanoma of the skin in Jews increased from 1980–2008 and decreased from 2008–2010. In non-Jews incidence rates have been unstable.
During 2000–2010 incidence rates of leukemia in children, ages 0–4 have been unstable (minor increase in both Jewish males and non-Jewish females and a decrease in both Jewish females and non-Jewish males). Incidence of in situ breast cancer increased both in Jewish and Arab women from 1990 to 2010 (the increase since 1996 can be explained by the National Mammography Program). Incidence of invasive breast cancer increased in Jewish women between the early 1990s and 1998 and then decreased steadily until 2010. In Arab women, invasive breast cancer rates more than doubled between 1990 and 2010, possibly due to improved diagnosis and socioeconomic changes in the population during that time. Age-standardized testicular cancer rates in Israel increased from 2.28 (per 100,000) in 1980 to 4.68 in 2010 in Jews and from 0.60 to 1.39 in non-Jews (Figure 1).
Figure 1: Age-Adjusted Testicular Cancer Rates in Israel, 1980–2010
Reproductive Health Trends
Infertility can be caused by a range of factors including aging, genetic abnormalities, acute and chronic disease, behavioral factors, and exposure to environmental contaminants. Low-level exposure to EDCs and ETS, including in utero exposure to these contaminants has been associated with decreased fertility. In Israel, fertility rates were generally stable between 2000 and 2012. In Jews, fertility rates increased from 18.7 (per 1,000) to 21.1 in 2012. In Arabs, fertility rates decreased from 35.0 (per 1,000) to 24.8. The male/female ratio in live births is 1.06 and has remained stable between 2000 and 2012.
Data are not available on current infertility rates. The rate of IVF treatment cycles (per 1,000 women aged 15–49) has increased in Israel from 11.5 in 2000 to 20.1 in 2012. The percent of live births from IVF (out of total live births) has increased from 2.5% in 1997 to 3.0% in 2001, to 3.3% in 2005, to 4.1% in 2009–2010, and to 4.4% in 2012. Much of the increasing demand for IVF treatments in Israel is attributable to economic and social factors (including state funding of fertility treatment). Age of menarche, which has also been linked to exposure to EDCs, exhibits a clear downward trend from 13.4 in women born in 1970 to 12.8 in women born two decades later.
While the major risk factors for obesity are generally considered behavioral (high calorie fatty diets combined with a sedentary lifestyle), the risk of obesity is also related to genetic and environmental factors. Recent toxicological and epidemiological studies indicate that in utero exposure to EDCs during development is associated with obesity and overweight later in life. Based on self-report in 2010–2012, 34.1% of adults 21 and older were overweight, while 15.7% were obese. In children, in 2013, 20.3% of first-grade students were overweight or obese, while 30.4% of seventh-grade students were overweight or obese. According to CBS data 50.1% of the population in Israel 15 and older is overweight or obese.
Exposure to EDCs has been linked to diabetes and prediabetic disturbances. For example, high dioxin levels have been associated with increased risk for diabetes or altered glucose metabolism. In Israel, there has been a monotonic increase in childhood Type 1 diabetes (ages 0–17), from 8.0 per 100,000 in 1997 to 13.9 per 100,000 in 2011 (Figure 2).
Figure 2: Incidence Rate (per 100,000) of Type 1 Diabetes in Children, 1997–2011
In adults, incidence rates increased from 1997 to 2011 in both Jews and Arabs, with a 44% increase in incidence among Jews and a 55.6% increase among Arabs. Mortality rates from diabetes (including both Types 1 and 2) increased dramatically in Israel from the early 1980s to 1999 and since then have steadily decreased.
Selected congenital anomalies have been linked to in utero environmental or occupational exposures to chemicals, radioactivity, and ambient air pollution. The WHO estimates that 5% of all congenital anomalies are attributable to environmental factors. The rate of congenital heart malformations, which has been linked to ambient air pollution, has been stable from 2000–2010. The rate of hypospadias, a malformation of the male urogenital system which has been linked to exposure to EDCs, has increased slightly from 31.73 per 100,000 in 1974–1978 to 33.4 per 100,000 in 2004–2008.
Progress and Challenges
Although Israel does not yet have a formal environmental health indicators program, when comparing the data currently collected in Israel to other such programs, it is undoubtedly feasible to develop environmental health indicators for Israel. This, however, is not without its challenges. It will require coordination among the various entities responsible for different types of data collection, as well as mechanisms for validation and quality assurance. Making collected data on both environmental factors and health endpoints accessible to researchers, policy makers and the wider public, in a timely fashion, will be critical to the success of this endeavor.
This chapter and all other chapters in the report was written by a team of scientists and professionals from the Ministry of Health, in collaboration with Environment and Health Fund.
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