Inequalities, inequities, environmental justice in waste management and health

Abstract

The scientific evidence on the health effects of waste-related exposure is not conclusive. Differential exposure to waste by socio-economic status (SES) is often documented, but the interplay between environmental and social factors, crucial for policy making, is not well known. This review aims at investigating the role of health inequalities and inequities in waste management.
Grey and peer-reviewed literature, published after 1983, was reviewed from Europe and the USA.
Available data provide consistent indications that waste facilities are often disproportionally more located in areas with more deprived residents, or from ethnical minorities. This applies to waste incinerators, landfills, hazardous waste sites, legal and illegal. In studies considering health effects (mainly from Europe), risks are estimated with standardization for SES. Such standardization almost always decreases risk estimates for several cancers and reproductive outcomes. However, effect modification is not investigated in these studies.
The patterns of association between waste-related environmental pressures and SES suggest that some of the observed inequalities in exposure and health represent a case of environmental injustice as they are the result of social processes and may be prevented, at least partly. Disentangling the possible health effects remains difficult, due to limitations in the methodology. It seems important to investigate if disadvantaged people are more vulnerable, i.e. risks differ in different social groups living in the same area. Notwithstanding these open questions, public health officers and decision makers should identify waste management policies to minimize their potential health impacts and their unequal distribution.

Full text

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Inequalities, inequities, environmental justice
in waste management and health
Marco Martuzzi
1
, Francesco Mitis
1
, Francesco Forastiere
2
Background: The scientific evidence on the health effects of waste-related exposure is not conclusive.
Differential exposure to waste by socio-economic status (SES) is often documented, but the interplay
between environmental and social factors, crucial for policy making, is not well known. This review aims
at investigating the role of health inequalities and inequities in waste management. Methods: Grey and
peer-reviewed literature, published after 1983, was reviewed from Europe and the USA. Results:
Available data provide consistent indications that waste facilities are often disproportionally more
located in areas with more deprived residents, or from ethnical minorities. This applies to waste
incinerators, landfills, hazardous waste sites, legal and illegal. In studies considering health effects
(mainly from Europe), risks are estimated with standardization for SES. Such standardization almost
always decreases risk estimates for several cancers and reproductive outcomes. However, effect
modification is not investigated in these studies. Conclusions: The patterns of association between
waste-related environmental pressures and SES suggest that some of the observed inequalities in
exposure and health represent a case of environmental injustice as they are the result of social
processes and may be prevented, at least partly. Disentangling the possible health effects remains
difficult, due to limitations in the methodology. It seems important to investigate if disadvant-
aged people are more vulnerable, i.e. risks differ in different social groups living in the same
area. Notwithstanding these open questions, public health officers and decision makers should
identify waste management policies to minimize their potential health impacts and their unequal
distribution.
Keywords: adverse effects, environmental exposure, hazardous waste, health effects, social class, socio-
economic factors
................................................................................................
Introduction
Waste and health: scientific evidence and
knowledge gaps
Given the growing production of waste, policy-makers are
increasingly confronted with the necessity of developing
more capacity to safely dispose of waste. Despite the lack of
univocal evidence on the health implications of waste-related
environmental exposures, there are concerns over the health
effects of different waste management options, including land
filling, incineration, disposal of healthcare and other hazardous
waste.
1
Further insights on health effects of landfills and incinera-
tors are needed; it is important to investigate these possible
effects in conjunction with other environmental hazards, as
concurrent exposures can result in synergistic health effects.
In particular, it is of interest to consider how possible health
effects of waste may take place in combination with other
powerful health determinants depending on lifestyle and the
social environment. It is urgent to clarify how population
distribution of waste-related exposures (i.e. how uneven are
such exposures among different subgroups) can inform the
policy response, affect its effectiveness and acceptance, and
how these aspects can be taken into account more system-
atically in policy-making. In particular, it is of great interest
to clarify what proportion of health inequalities (i.e. general
differences in health status and in exposure levels due for
example to age or individual predisposition) can be regarded
as inequities (i.e. avoidable differences, for example in access
to healthcare service, preventing individuals from attaining
their full health potential, and carrying an ethical negative
judgement) and as such result in environmental injustice.
The present contribution is dedicated to the role of socio-
economic differences and environmental justice on the
potential health burden due to exposure to hazardous waste
facilities.
Role of social health determinants
Social determinants of health have a strong influence on
virtually all health endpoints considered in studies designed
to assess the role of waste–related exposure. As in many
other fields in environmental health, this realization has
resulted in the adoption of methodology to formally take
into account these effects in epidemiological studies.
Typically, socio-economic factors have a strong potential for
acting as confounders of the parameter of interest, i.e. the
association between health and waste exposure. This is
because exposed subjects often have socio-economic char-
acteristics that can differ from those of unexposed subjects,
and thus create differences in risk that could be erroneously
attributed to waste. This is why effects of socio-economic
factors are often regarded, in epidemiological studies, as
nuisance factors, and standardization techniques are applied
to remove their contribution and assess the waste–health
association, net of the influence of socio-economic factors.
This routine standardization reflects the strong expectation
that socio-economic factors are associated with environmental
exposures—a prerequisite for a confounding effect. The
systematic adoption of this practice relies on an important
assumption, and suggests a certain attitude: the assumption
is hazard proportionality, i.e. health risks from socio-
economic conditions act as multipliers of an independent
1
World Health Organization (WHO) Regional Office for Europe,
Rome Office, Rome, Italy
2
Local Health Authority Roma E, Rome, Italy
Correspondence: Marco Martuzzi, World Health Organization
(WHO) Regional Office for Europe, Rome Office, Via Francesco
Crispi, 10-I-00187, Rome 00198, Italy, tel: +39-06-4877520,
fax: +39-06-4877599, e-mail: mam@ecr.euro.who.int
European Journal of Public Health, Vol. 20, No. 1, 21–26
ßThe Author 2010. Published by Oxford University Press on behalf of the European Public Health Association. All rights reserved.
doi:10.1093/eurpub/ckp216 Advance Access published on 8 January 2010
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risk due to environmental factors. In other words, through
standardization for socio-economic factors the environmental
risk is assumed constant across different social strata, and the
possibility of modification of effect (for example, different risks
for different socio-economic groups) is seldom investigated.
The attitude is the one of considering the multiple effects as
independent of each other and attaching less importance to
the contextual ones. Admittedly, full, holistic consideration of
the mutual action of different risks is very challenging and is
often not feasible; however, a fuller understanding of how
environmental risk factors operate in the reality of the social
environment would be very informative especially for
designing effective policy responses.
In this paper we examine the evidence and the implications
of the confounding effect of socio-economic factors. First of all
then, we address the question of how strong is the evidence
that more deprived communities are more exposed to waste-
related contaminants; later, we examine how these gradients,
where observed, can influence the risks for several health
endpoints, considering how risks differ before and after
adjustment for socio-economic factors. Finally, we discuss
the implications of these inequalities.
Methods
Grey and peer-reviewed literature, published after 1983, when
an influential paper appeared,
2
was reviewed from Europe and
the USA.
Keywords or references in the titles to ‘waste’, ‘health
effects’, ‘socio-economic factors’, ‘inequities’, ‘environmental
justice’, ‘congenital anomalies’ and ‘mortality’ were used to
search the Medline database. All European studies were
selected. With regard to US studies, given the large amount
of literature dealing with social differences on the residence
near waste facilities, only the most s studies were chosen
and commented. The grey literature was searched with the
same criteria using Google Scholar and looking at the key
references listed in the peer-reviewed articles to identify
nongovernmental organization (NGO) reports and studies
published by other agencies. A total of 47 studies were
included in the review.
Results
Residence near waste facilities: unequal
and inequitable
The characteristics and main findings of the identified studies
are summarized in Supplementary Table 1.
The first studies on environmental justice, contaminated
sites and waste were carried out in the USA and were
prompted by the concerns of civil activists on the dispro-
portionate location of landfills in predominantly black
communities.
3
The correlation between race, income and
residence influenced several outcomes such as a higher
likelihood of being exposed to environmental hazards, the
disproportionate impacts of environmental processes and
policies, the targeting and siting of noxious facilities in more
deprived communities and inequalities in the delivery of
environmental services such as rubbish removal.
4–6
Other studies found skewed distributions around waste
sites, with less affluent population subgroups, and with more
black people, living in the surroundings of the facilities.
2,7–9
In a US national assessment
10,11
(later updated
12
), a correlation
was found between proportion of black residents and
the presence of hazardous waste sites in the surroundings.
Although these results were criticized,
13–16
ethnicity was
considered to be a stronger predictor of the presence of toxic
dumps than other variables, such as household income,
the value of homes and the estimated amount of hazardous
waste generated by local industry.
Brown
17
reviewed (i) exposure to toxic hazards, includ-
ing the presence of hazardous waste sites and facilities
(ii) regulations, ameliorations and cleanups, including record
of decisions and cleanups at National Priority List (NPL) sites
and (iii) regulatory actions, as measured by assessed fines for
environmental pollution; he concluded that ‘the overwhelming
bulk of evidence supports the ‘‘environmental justice’’ belief
that environmental hazards are inequitably distributed by
class, and especially race’. These results were confirmed by
the most recent study,
18
and the underlying social processes
were analysed in different settings.
15,19,20
Compared to US studies, European data are based on a
different approach to measuring socio-economic status
(SES), based on composite indices built combining infor-
mation on several domains, such as social class, education,
unemployment, housing, family structure, rather than
variables such as income or ethnicity.
The association between social characteristics and resid-
ence in the vicinity of waste sites has been repeatedly
documented in England and Wales. Several studies analysed
the correlation between income and deprivation with local-
ization of solid waste and other polluting facilities, finding
that facilities were disproportionally located in the more
deprived areas.
21–23
The correlation was not always observed
for landfills at the subregional level.
24
At the national level, a study by Elliott et al.
25
showed that
‘the area within two km of the 9565 landfill sites tended to be
more deprived than the reference area: 34% (versus 23%) of
the population were in the most deprived tertile of Carstairs
score (36% for special waste sites)’.
A national study on environmental inequalities in France on
the distribution of environmental burden tested the hypothesis
that poor and immigrant communities are disproportionately
exposed to environmental risks. Eight types of hazardous sites
(industrial and nuclear sites, incinerators, waste management
facilities) and the socio-economic characteristics of popula-
tions were associated at the commune, or town, level for all
36 600 French towns. The results of the spatial regression
analyses showed that towns with high proportions of
immigrants hosted more hazardous sites, even controlling for
population size, income, degree of industrialization of the
town and region.
26
In the European Union project Integrated Assessment of
Health Risks of Environmental Stressors in Europe
(INTARESE), an integrated approach for the health impact
assessment of landfills and incinerators on the population
living in the surroundings has been applied in Italy, UK
and Slovakia, for a total 905 municipal urban solid waste
landfills and 53 waste incinerators.
27
A direct relationship
was found between social class and residence near waste
facilities in Italy and UK, and an inverse relationship was
found in Slovakia (Table 1). For incinerators, this may be
due to the location of the two facilities in urban areas, where
most affluent Slovakian people live.
The results of European Collaborative Study of Residence
near Hazardous Waste Landfill Sites and Risk of Congenital
Malformations (EUROHAZCON),
28
a multisite study that
considered 21 landfills in several countries, suggested
‘no overall evidence that socio-economically more deprived
communities live near to landfill sites’.
An inverse relationship was also found in a study of a Welsh
landfill, where most affluent people were found to be living
closer the site.
29
Cancer mortality and congenital anomalies of populations
living in 196 municipalities of two provinces of Campania
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Region, southern Italy, were recently investigated.
30
The study
area was characterized by more than 20 years of waste
mismanagement (with the involvement of organized crime),
including uncontrolled waste disposal, release of toxic
substances and illegal waste burning. A positive correlation
(r= 0.30) was found at municipality level between a waste
exposure indicator (built using 227 waste facilities sites–138
of which illegal) and a deprivation index.
30
Interest in environmental justice and in unequal distribution
of environmental hazards and benefits has recently grown in
countries of central and eastern Europe. It has been
documented that hazardous sites and illegal waste disposal
activities are disproportionally located in the working-class
areas, as in Hungary with illegal asbestos disposal,
31
and in
communities of ethnic or national minorities, predominantly
the Roma populations,
32–34
whose camps are often settled on
(or near) contaminated sites. The Hungarian National Public
Health and Medical Officers’ Service reported, for example,
that 15% of the 767 Roma colonies identified in Hungary,
for a total of three million persons, are within 1 km of illegal
waste disposal sites, and 11% within one km of animal carcass
disposal sites.
35
In addition, minority groups in European countries are
more at risk of environmentally based discrimination
because they are more likely to be object of discrimination,
and be segregated in enclaves or in deprived zones along the
borders, or in refugee camps.
33,36,37
Finally, besides differential levels of exposure to waste-
related contaminants by socio-economic levels at local or
national level, inequalities in exposure might take place at
the international level, through the transfer of related
hazards from one country to another.
38,39
In fact, illegal
shipment and disposal of hazardous waste is of growing
relevance in some countries of central and eastern Europe.
40,41
Exposure to waste and socio-economic factors:
compounded effects
Many of the studies above, especially from Europe, document
a pattern where deprived people are overrepresented in the
vicinity of waste treatment facilities. In some of these studies,
in addition, it is observed that health effects—notably
mortality, congenital anomalies, low birth weight—are
associated with socio-economic factors.
Several studies were performed in UK on congenital
anomalies,
25,42
Down syndrome
43
and cancer
44
in population
living near landfills. In a recent study on congenital anomalies
and landfill density, risks were standardized by SES, presence
of a congenital anomalies registry and maternal age. On
adjusting for these factors, risks decreased for all the
anomalies under study, more markedly in areas with the
highest special waste sites density.
25
In a subsequent study
43
a decreasing risk of Down’s
syndrome with increasing levels of socio-economic deprivation
was observed; however, adjustment for SES resulted in a
marginal correction of the estimates of the risks from
landfills, perhaps not surprising because of the strong effect
of maternal age.
In another UK study on cancer and residence near landfill
sites,
44
adjustment for SES decreased the risk estimate for
bladder cancer, which however remained significantly in
excess. The same was observed for hazardous sites, but the
adjusted risk for bladder cancer lost statistical significance.
In the EUROHAZCON multi-site study a positive
association was reported in the UK between SES and non-
chromosomal congenital anomalies close to landfills.
28
The
risk in the most deprived group was 40% higher than in the
most affluent quintile; an impact measure was also estimated:
if the rates observed in the most affluent group prevailed in the
whole exposed population, the 18% fewer anomalies would
have occurred.
45
This pattern was not observed in other
European sites.
In a study carried out in Campania a positive association
was observed between mortality for various cancer causes and
both illegal waste exposure and socio-economic factors. For
both sexes, mortality risk estimates unadjusted by socio-
economic deprivation were much higher than adjusted ones,
as shown in Table 2. Risk estimates were markedly corrected
across the five levels of waste exposure, and so were estimates
of linear trends. The only exception was stomach cancer in
men.
46
In a study in the New York state near PCB-contaminated
(i) superfund sites, (ii) NPL sites and (iii) the six areas of
concern,
47
the risk of giving birth to a low-birth-weight and
to a very low-birth-weight baby was investigated. Positive
associations were observed between having a low-birth-
weight baby and (i) low levels of income and (ii) mother’s
educational level less than (or equal to) high school while
only a low-income level was associated to having a very
low-birth-weight baby.
Another US study
48
considered only ethnic minorities
(Black/African American, Hispanic/Latino, American Indian/
Alaska Native and Asian/Pacific Islander) and found a positive
association between a range of anomalies and residence in the
census tracts near the NPL hazardous waste sites. The largest
association was found between potential exposure and
neural tube defects [odds ratio (OR) = 1.54, 95% confidence
Table 1 Characteristics of residents living close to waste facilities
a
in Italy
b
, Slovakia and England, by quintiles of deprivation
index, 2001
Landfills Incinerators
Italy Slovakia England and Wales Italy Slovakia England and Wales
Number of sites 619 165 232 40 2 11
Population within 2 km 1350 852 328 869 1425 350 1060 569 16 409 1203 208
Most affluent population (I group, %) 13.3 24.2 2.5 12.6 55.6 30.
II group 15.0 24.7 17.9 15.1 2.4 6.3
III group 22.4 22.6 18.7 21.0 9.8 12.5
IV group 23.0 16.4 19.1 24.2 29.6 22.8
Most deprived population (V group, %) 26.1 12.1 20.1 24.9 2.5 55.4
Missing information (%) 0.0 0.0 21.7 2.2 0.2 0.0
Source: adapted from Forastiere et al.
27
a: 2 km from municipal urban solid waste landfills; 3 km from waste incinerators
b: 118 landfills were geocoded, for population of 257 513. Socio-economic data were then extrapolated to 619 landfills
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interval (CI) = 0.93–2.55]. The strongest association between
birth defects and potential exposure was among American
Indians/Alaska Natives (OR = 1.19, 95% CI = 0.62–2.27). This
study design, however, does not allow a comparison with the
effects in the majority population.
Discussion
Waste and health: same risk for everyone?
The evidence summarized above indicates that there is a
tendency in poorer, less educated, disadvantaged people or
ethnical minorities to live closer to waste treatment facilities
of any kind and, in addition, that when adverse health
effects due to such proximity are detected, these are often
compounded (usually multiplicatively) with the adverse
effects of social disadvantage. This pattern may occur for
other localized source of environmental pollutants, but is not
systematically documented. On the whole, the evidence
suggests marked inequalities in the health pressures and
impacts due to the combination of environmental and social
factors. Some of these inequalities are due to socially driven
processes, for example residential segregation or differential
access to health-promoting resources, amenable to mitigation.
Some questions arise from these observations.
Are disadvantaged people, besides being disproportionally
exposed to waste-related environmental risk, also more
vulnerable to its impacts?
Do risks differ in different social groups living in the same
exposed place and, if so, to what extent?
In other words, is there an interactive, synergistic relation-
ship between the adverse health effects of waste exposure
and of the disadvantaged social environment, or conversely
does the proportionality assumption hold?
How preventable are the observed inequalities?
The available information on the health effects of waste
facilities by social groups, needed to address these questions,
is limited. First, not all the studies carried out to evaluate the
potential associations between exposure to waste facilities and
health have considered SES; in some studies, socio-economic-
adjusted risks are estimated but unadjusted risks are not
published, or are indistinguishable from those due to other
factors (for example, maternal age or the presence of a
dedicated registry in studies of congenital anomalies).
Secondly, and crucially, in no cases are interaction effects
between socio-economic factors and waste exposure tested
and reported. Some studies are designed with selected popu-
lations either highly exposed
47
or from socially disadvant-
aged,
48
making the assessment of the interaction impossible.
For waste and health as well as for many other cases in
environment and health, these issues are central; together
with better quality data on waste-related exposures,
recognized as a prerequisite for more informative studies,
1
more detailed information on exposure and health by the
socio-economic group would not only shed light on the
nature of the interrelationship between the social and the
physical environment but would also allow the identification
of more effective strategies to prevent or reduce the impacts.
There are, however, substantial difficulties in estimating
the joint effects of different risk factors, for example,
low power to estimate interactive effects, given the high
collinearity between environmental exposures and depriva-
tion. This is one facet of environmental justice: different
risk factors, such as environmental contamination, social
disadvantage, unhealthy lifestyles, are often observed to
insist on the same subgroups. This makes the assessment
of the interplay between these different factors difficult
and represents an important reason to consider inequalities
Table 2 Waste exposure, SES and mortality outcomes in Campania region
a
Mortality excess (%) risks by waste exposure group
b
I II III IV V Trend
Unadj Adj
c
Unadj Adj Unadj Adj Unadj Adj Unadj Adj
Cause of death—men
All causes — 9.2 5.4 6.9 7.9 7.1 3.9 13.6 9.2 2.2 1.7
All cancers — 9.3 4.2 3.2 5.6 9.3 4.9 11.0 4.1 2.2 1.5
Lung cancer — 11.4 5.5 4.2 6.4 11.1 6.1 14.0 6.7 2.7 1.9
Liver cancer — 0.1 9.2 12.7 20.6 7.0 0.7 35.5 19.3 5.6 4.3
Stomach cancer — 1.5 3.0 0.1 2.8 17.0 19.4 16.2 15.7 5.0 5.2
Bladder cancer — 17.3 11.7 11.0 6.4 10.8 7.1 4.6 4.1 0.8 0.7
Kidney cancer — 4.4 2.8 4.3 0.6 8.5 14.9 7.6 16.7 3.0 4.0
Soft tissues sarcoma — 10.6 9.8 7.2 20.4 23.6 31.0 18.7 25.0 3.1 3.9
Non Hodgkin lymphoma — 24.2 9.4 29.8 25.4 18.7 6.8 2.8 3.7 2.3 1.3
Other cancers — 9.1 4.7 2.4 4.3 7.6 3.3 6.2 0.3 1.4 0.7
Cause of death—women
All causes — 3.1 1.7 7.2 8.1 5.6 4.8 14.4 12.4 2.6 2.4
All cancers — 9.8 5.1 2.3 2.4 6.7 3.6 10.0 6.6 1.6 1.0
Lung cancer — 63.8 45.4 10.2 14.4 14.1 5.6 22.7 9.4 0.2 2.3
Liver cancer — 3.5 9.3 5.0 9.1 13.6 9.6 39.5 29.1 7.3 6.6
Stomach cancer — 8.1 8.3 2.3 6.4 1.0 2.2 10.7 16.7 2.1 2.6
Bladder cancer — 17.9 7.7 6.5 12.7 3.2 2.8 17.3 16.7 2.8 3.3
Kidney cancer — 19.2 6.9 2.4 11.2 8.7 3.4 36.2 19.1 3.8 1.7
Soft tissues sarcoma — 4.3 7.7 76.0 84.1 35.2 33.6 4.2 0.3 7.8 8.3
Non Hodgkin lymphoma — 9.8 10.1 3.3 3.5 15.9 19.7 2.1 0.2 1.8 1.6
Other cancers — 7.4 3.5 1.3 1 5.2 2.3 6.3 3.7 1.1 0.7
Source: Adapted from Martuzzi et al.
30
a: In bold, statistically significant risks are reported (95% CI)
b: I group is used as reference, i.e. no waste-related exposure; V group has highest exposure
c: Mortality excess risks (%) = (relative risk 1) 100. Risks adjusted by SES
24 European Journal of Public Health
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(in exposure and in health outcomes) as inequities. Other
relevant considerations in terms of equity include the
following.
While a certain degree of inequalities are inevitable, at least
a part (arguably a substantial one) of the observed
inequalities is preventable. Exposure inequalities can and
must be reduced by appropriate measures of mitigation
and abatement of emissions from potential sources. This
includes not only established noxious agents (for example,
particulate matters, persistent organic pollutants, heavy
metals) but also emissions interfering with residents’
quality of life (for example, odours, noise). Inequalities
can be further countered by primary prevention and
health promotion initiatives undertaken in conjunction.
It is possible that people who bear the most part of the
adverse impacts from waste disposal activities (in terms of
health and well-being) produce less waste. This might
occur, for example, when residential exposures are
disproportionately distributed towards population strata
with lower income, lower purchasing power and lower
rates of consumption of material goods. There are
examples, in other domains, where this unfair, negative
correlation between benefits and negative impacts is
obvious (for instance, greenhouse gas emission at global
level) and similar mechanisms may take place at more
local level too.
Currently, both of these dimensions of environmental
justice are, by and large, speculative. Data and evidence to
assess the extent of these inequities would be highly
informative.
Conclusions
Numerous studies in Europe and in the USA have documented
that disadvantaged communities often suffer disproportion-
ately from the impact of waste facilities. Several questions
are unresolved that should be addressed with the collection
of targeted data and research. Uncertainties include the
presence and magnitude of environmental different waste-
related risks, the possible synergistic effects with the social
environment, the extent to which inequalities are preventable
and the degree to which benefits and adverse impacts are
differentially distributed in the population. However, while
these knowledge gaps are being filled, public health profes-
sionals should contribute to the identification and develop-
ment of waste management policies that minimize health
impacts and inequalities. In the words of Mohan:
49
Health inequalities should be one of the key considerations
when developing waste management strategies or when
conducting HIAs of waste sites. If waste management
installations are to be located in an area, every effort
should be made to mitigate any potential adverse health
effects. [...] Every effort should also be made to ensure
that the local community enjoys any potential benefits
from waste management.
For waste management as well as for other domains, a direct
participation of the health sector in the decision-making
process is desirable. Participatory processes are necessary to
achieve fairer policies, where the interests of all stakeholders
are taken into consideration. In view of the various limitations
hampering our ability to characterize all risks, policy decisions
on new facilities and remediation schemes should be inspired
by a precautionary approach,
9
where health and equity are put
at the centre of the debate.
Supplementary data
Supplementary data are available at EURPUB online.
Acknowledgements
The authors would like to acknowledge Lubica Palkovicova
and Kees De Hoogh for providing data on Slovakia and UK.
They are grateful to Pietro Comba for his useful suggestions.
Funding
Partly funded by INTARESE, an Integrated Project of the EU
6th Framework Programme.
Conflicts of interest: None declared.
Key points
The expectation that waste-related environmental
exposure is stronger in disadvantaged population
subgroups is confirmed by most studies available in
Europe and the USA.
The effects of socio-economic health determinants are
often removed, through standardization, in epidemio-
logical studies; the possible occurrence of modification
of effect would be of great interest, but is not
documented.
Despite the limited understanding of the interplay
between waste-related exposures and social health
determinants, observed patterns raises a question of
environmental justice, which require adequate policy
responses.
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Received 19 August 2009, accepted 1 December 2009
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