National Health Programme

II. MOST SERIOUS HEALTH HAZARDS AND MAJOR HEALTH PROBLEMS

1. MOST SERIOUS HEALTH HAZARDS

Health-damaging behaviour

Lifestyles and health behaviours determine, to the greatest extent, the health status of the population. In Poland, much has to be improved in this area. Health-damaging practices include first of all:

Hazards in the social environment

The social environment, interpersonal relations, communication within the family, at work, at school and other educational institutions, and within the local communities together with economic factors impose profound effects on the psycho-physical condition and the health status of the population. The process of political, social and economic transformations initiated in 1989 creates new opportunities for people but at the same time it brings about new threats to their health. Among most serious health hazards the following should be identified:

  1. Growing inequality in the access to fundamental resources indispensable for health maintenance and health gain such as food, decent housing, cloth and work:
  2. Dependence of a large group of the population (8% at present) on social welfare while the state decided at the same time to withdraw from various forms of social allowances and benefits, including inter alia those formerly existing in the area of health care.
  3. Difficult situation in the field of education, science and culture manifested by financial constrains, low educational level in society (only 7% of people are university graduates) and the declinng proportion of children benefiting from the care rendered by nurseries and kindergardens, particularly in rural areas (growing social inequalities).
  4. Expansion of numerous social pathologies leading, among others, to lack of security among people, weakened family ties, increased crime, occurrence of a new phenomena such as criminal terrorism, increasing health and social problems related with alcohol and drug abuse.
  5. The growing occurrence of so called "syndrome of hopelessness", characteristic for persons who are convinced that nothing can be changed unless for the worse, manifested by a growing number of suicides (5.499 in 1995).
Hazards in the physical environment

Threats to human health and wellbeing that occur in the physical environment arise from growing industrialization and urbanization, wrong ecological policy and lack of concern about the healthy environment inherited from the former regime. In those times community awarness of the impact of the environmental pollution on human health and the evaluation of its adverse effects were far from satisfactory. All these have contributed to a considerable degradation of the environment in Poland and only since recently the environmental pollution and related health problems have been gradually reduced. In Poland sulphur dioxide (SO2), black smoke and nitrogen dioxide (NO2) are major pollutants of the atmospheric air. Although positive tendencies in the reduction of SO2 and NO2 emissions have been observed since the late eighties a wide gap in the range of developments in this area still separates Poland from majority of European countries. As a result of cross-border transport of air pollution, about 87% of nitrogen oxide, 75% of sulphur oxide and 49% of ammonia produced in Poland are transported outside its national border. At the same time about 60% of sulphur and about 80% of oxidized nitrogen deposited on the territory of Poland come from abroad.
Together with the reduced emissions of pollutants their concentrations in the atmospheric air diminish gradually, and the situation improves in many big cities. Despite this positive tendency, in 1994 exceeded MAC values were found in more than 100 administrative units of the country.
Since the eighties the number of untreated industrial and communal sewages disposed to surface waters has been reduced. However, one fourth of sewages still remains untreated. Considerable areas of surface waters are polluted. Almost half of river sectors under control are overpolluted by chemicals, and according to the biological criterion as many as 90% of them are highly polluted. The quality of tap drinking water (90% of the municipal supply system and over 70% of local water pipes) is generally classified as good. However, water from public and house-adjacent wells is in many cases of bad quality.
Traffic noise very often exceeds allowable levels and creates problems in many urban areas. Similar situation is caused by industrial plants whose noise exceeds allowable levels quite frequently at night.
Hazards in the working environment such as noise, vibration, dusts or volatile toxic substances are of great problem mostly because of insufficient protection of workposts aganist harmful factors.



National Health Programme

2. MAJOR HEALTH PROBLEMS

The overall health situation

Despite evident improvements in the health status of the population, observed since World War II, there is still a wide gap in overall health situation between Poland and western countries.
The first period after the war brought about the decrease in mortality in all age groups. That resulted in longer life expectancy which, in mid sixties, was comparable to that observed in Austria and Finland. The positive change was mainly due to a reduction in mortality from communicable diseases. Later on, the health condition of middle-aged men started to decline and this process has continued over successive years. Women's health condition worsened during the seventies, however, the change was not so extensive.


Fig. 2. Male life expectancy at birth (number of years), in Poland, all Europe (Europe), Central and East Europe (Eur. S-W) and in the European Union (UE) in 1970-94.

Since 1991 the health situation has begun to improve. Total mortality has dropped down, but premature death rate remains still very high. At present one third of deaths is noted in persons under 65 years of age. If current mortality pattern remains, 36% of men and 16% of women born in 1994 are not likely to reach the age of 65 years. In Poland the risk of premature male death is by 60% higher than average in Europe, whereas among women this excess accounts for about 30%.


Fig. 3. Female life expectancy at birth in Poland and Europe (Europe), 1970-94.

Life expectancy at birth for men which accounted for 67.6 years in 1995 and for women 76.4 is considerably lower than in the whole Europe and in Member States of the European Union (Figs 2 and 3).
The analysis of the recent health situation in Poland indicated a decline in overall mortality and mortality from diseases of the circulatory system (major cause of death). It may be presumed that this positive trend will continue to maintain in future.

Infant mortality

Infant mortality gradually decreases, however, the pace of the decrease varied in different periods of time: during the years 1960-74 annual decrease in infant mortality rate accounted for 4.7%; in 1974-90 - 3.4%; and in 1990-94 - 6%. Higher rates than in Poland have been observed only in some countries of the former communist block, while in majority of European countries the infant mortality rates is twice as low. Infant mortality is associated, to a great extent, with prematurity and low birth weight quite common in Poland. In 1995 the proportion of infants with low birth weight (below 2.500) reached 6.2% and as much as two third of total infant deaths occurred in this group of newborns.

Diseases of the circulatory system

Cardiovascular diseases are a major public health problem in Poland like in other developed countries. In 1995 they caused 50.4% of all the deaths, that is 194,710 (Fig. 4).


Fig. 4. Male and female mortality by main categories of diseases, 1994 (in %).

Cardiovascular diseases mortality rates have declined in all developed countries since mid seventies. At the same time the incidence of these diseases has been increasing in Poland, particularly in the male population. This adverse trend reached its peak in 1991 and since then a long expected declining tendency has been observed (Figs 5 and 6). In the early nineties male mortality from cardiovascular diseases in Poland was higher by 60% than the mean in Europe and by 90% than the mean in the European Union Member States. The excess of rates for women accounted for 46% and 81%, respectively. When compared with European countries of the former communist block the rates for males are close to average and for women they are lower.


Fig, 5. Cardiovascular diseases standardized mortality rates for men in Poland and Europe, 1970- 94.

Fig, 6. Cardiovascular diseases standardized mortality rates for women in Poland and Europe, 1970-94.

The increased incidence of arteriosclerotic vascular disease, and particularly of ischaemic heart disease and cerebrovascular disease, contributes most to the raised cardiovascular disease mortality rates. A higher risk of arteriosclerotic vascular disease is associated with a high incidence of arterial hypertension. It is estimated that about 20% of the adult population in Poland suffers from hypertension. Cardiovascular diseases belong now to the most frequent cause of hospitalization. During the years 1979-94 the proportion of in-patients hospitalised due to these diseases increased from 15% to 20% among men and from 11% to 16% among women.
Further improvement in the efficiency of health services, and cardiovascular emergency service in particular, is vital since according to the data available, about 30% of men and 20% of women with myocardial infarction die before being hospitalised. The elapse of time between the onset of the symptoms, arrival of an ambulance and hospitalization is still too long.

Malignant neoplasms

Malignant neoplasms form the second group of major causes of mortality in Poland being responsible, in 1994, for 21.5% of all deaths in men and almost 18% in women. In the seventieth the risk of malignant neoplasms in Poland was much lower than in the majority of European countries. During the next decade overall male mortality from cancer increased. At present male and female mortality rates, especially in the 20 - 64 age group, is higher than the average in the whole Europe, including postcommunist countries. The data obtained recently indicate a reverse tendency and a gradual decline in mortality from malignant neoplasms can be expected.
The most dynamic increase is observed in mortality from the trachea, bronchia and lung cancer. Over the last years mortality from this cause was higher in Poland by about 30% for men and by 8% for women than the average values in Europe (Figs 7 and 8). Recently, this tendency has changed and mortality rates begin to decline. However, a higher risk of neoplasm of the lower alimentary tract (especially rectum) and pancreas is observed together with a dramatic increase in risk of malignant melanoma.
Since the eighties breast cancer has been the leading cause of death from cancer among women in Poland. Breast cancer mortality rate has remained stable since 1988 and now it is lower than in most of Europe.
In Poland the rate of mortality from malignant neoplasm of the cervix is one of the highest in Europe. At present a declining trend is being observed, however the decline is slower than in a majority of European countries.


Fig. 7. Malignant neoplasm standardized mortality rates for men in Poland and Europe, 1970-94.

Fig. 8. Malignant neoplasm standardized mortality rates for women in Poland and Europe, 1970- 94.

At present malignant neoplasms are the cause of every tenth hospitalization. During the years 1979-94 the contribution of these diseases as a cause of hospitalization doubled. In 1994 over 400 thousand cases of neoplasms treated in hospitals included more than 55 thousand cases of lung cancer, 33 thousand cases of breast cancer, and over 16 thousand cases of cancer of the lower alimentary tract. In 1979-94 lung cancer was the largest single contributor to the increased hospitalisation.

Injury and poisoning

External causes of injury and poisoning constitute the leading cause of death among males aged 1-45 and females aged 1-35. The situation in Poland in this regard is worse than the average in Europe in terms of both the level of mortality and the pattern of its change in time. In the early nineties the rate of mortality from injury and poisoning was higher by over 60% for men and almost 20% for women than the average for European countries (Figs 9 and 10).
Traffic accidents are still one of the main causes of death, and they constitute one fourth of all the deaths from external injury and poisoning for men and one fifth for women. Poland takes one of the leading place in Europe in the road accident mortality.
According to the 1995 data obtained from the Police Road Traffic Department, 6.900 persons involved in 56.904 road accidents died, what means that more than one person died in every tenth accident. The share of pedestrians' deaths in the total mortality due to road accidents accounted for 40%. The number of the injuried in road accidents was higher by ten times than the number of killed.
Bearing in mind that road accidents are one of main causes of death among young people (second, third and fourth decade of life), they are responsible for the largest number of lost potential years of life.
Another matter of great concern is that of suicides which constitute only a slightly smaller life threat than road accidents. The number of deaths due to committed sucides increased from 4.970 in 1990 to 5.499 in 1995. The male suicide rate is higher in Poland than the average in Europe whereas the female rate is lower.
In 1994 about 14% of men and 6% of women were hospitalised as a result of injury and poisoning. During the years 1979-94 the hospitalization rate in this group of causes remained at the same level.


Fig. 9. Standardized mortality rates of external causes of injury and poisoning for men in Poland and Europe, 1970-94

Fig. 10. Standardized mortality rates of external causes of injury and poisoning for women in Poland and Europe, 1970-94.



Diseases of the respiratory and digestive systems

In Poland every fifteenth death is caused by diseases of the respiratory or digestive system, and mortality rates in both groups of causes are the same. Since the mid eighties mortality rates of respiratory diseases have declined regularly. In the case of the diseases of the digestive system this decline proves to be slower. The mortality rates in both groups of diseases are lower than the average ones in Europe.
In the group of respiratory diseases, male mortality from chronic obstructive pulmonary disease (including asthma) is most frequent. Among women pneumonia constitutes a greater life threat. Mortality from cirrhosis predominates in the other group of diseases both in men and women.
Both categories of diseases are main contributors to hospital treatment of men: over one fourth of the total number of hospitalized cases. Among women they play less important role, however, every fifth woman treated in a hospital suffers from one of these diseases.
Pneumonia is the main cause of hospitalization in the category of respiratory diseases, and inguinal hernia in men and cholelithiasis in women among diseases of the digestive system.

Mental disorders

The size of this health problem is only partly reflected in registered rates of mental disorders treated in individual types of mental hospitals and other health service facilities. Since 1975 hospitalization rates have been relativly stable (about 450 cases per 100.000 population). Nevertheless, the number of new cases has increased - 59.000 in 1995: one third of the total number of patients with mental disorders. This figure results entirely from the increased number of patients with diagnosed alcohol-induced mental disorders hospitalized for the first time. In 1995 the number of these patients was three times higher than in 1970.
During the years 1985-94 general incidence of mental disorders registered in outpatient health service facilities was maintained at similar level (about 450 per 100.000 population). But a significantly growing tendency has been observed in the case of affective psychosis (an increase of 60%). On the one hand, environmental conditions, and the aging process of the population, and better diagnostic methods and easier access to mental treatment, on the other, contribute to the increased number of registered cases.

Communicable diseases

Despite favourable epidemiological situation, in Poland like in other countries the problem of infections transmitted via damaged tissues is challenging. In Poland this group of infections encompasses, first of all, viral hepatitis B. The number of hepatitis patients had decreased by the end of eighties and in 1995 over 9 thousand new cases were registered. Chronic inflammations, cirrhosis and liver cancer belong to the most frequent consequences of viral hepatitis.
The year 1994 was the fourth successive year with incidence of pulmonary tuberculosis higher than in 1990. In comparison to the mean values reported in Europe, the TB incidence maintains at much higher level in Poland, and it is close to the mean values noted in the group of postcommunist countries. Although, the number of TB cases has been also increasing in Western countries for the last few years, the gap between Poland and the European Union is still very wide. It is characteristic that in Poland TB is manifested by late clinical symptoms.
The epidemiological situation of HIV infections is rather favourable in Poland. It is estimated that most likely number of HIV carriers accounts for about 12.000. As of 30 April 1995 the total number of 421 AIDS patients were registered. Nevertheless, further increase in the number of HIV infections and AIDS patients should be expected.
It should be stressed that an adverse epidemiological situation observed in some neighbouring countries over the last few years may lead to the import of communicable diseases which do not occur in our country. Therefore, more effective preventive measures should be developed.

Occupational diseases and those related to work performance

For the last twenty years the incidence of occupational diseases has shown a growing trend ranging from 6.789 to 11.988 cases annually (from 56.7 to 131.1 per 100 thousand employed).
The present epidemiological situation as far as the incidence of occupational diseases is concerned as not related only to hygienic conditions at the work environment but also, and even to greater extent, to the efficacy of diagnostic methods.

Disability

It is estimated that in Poland there are about 4.8 million people with various disabilities. This figure applies to persons with disabilities certified by the Medical Commission for Disability. In about one third of cases disability occurred at the age between 40 and 50 years, and every twentieth person is disabled from birth or first year of life. Diseases of the musculoskeletal and circulatory systems are major causes of disabilty (60%). About 30% of disabilities result from injuries.

Dental caries and periodontal disease

Dental caries and periodontal disease are a major health problem which accurs generelly among children and young people and in almost all adults. The results of screening tests indicate an over 90% incidence of caries in children and a 98% incidence in adults, whereas periodontal disease occurs in 50% of children aged 12 and in 92% of adults under 45 years of age. Advanced phase of dental caries (extensive changes - more than one decayed, missing or filled teeth and complications) is found in over 60% of children aged twelve. Acute cases of periodontal disease which require a long-term, comprehensive specialistic treatment are observed in 15% of adults under 45. Dental caries and its consequences are a major cause of early loss of dentition.



National Health Programme

3. INEQUALITIES IN HEALTH

Gender

The most broadly availbale indicators of differences in health status are based on mortality. Poland belongs to countries with significantly marked excess male mortality, namely a higher rate of mortality among men in all age groups than among women. The excess mortality ranges between more than 10% among children aged 1 - 4 to 300% among adults aged 20 - 24.
All underlying causes of deaths are more dangerous for men than for women, and the greatest difference applies to mortality from external causes of injury and poisoning. Their threat to life is above three times higher for men than for women. The difference between male and female mortality rates is responsible for considerably shorter life span among men than among women. In 1994 the difference amounted to 8.6 years (by the year 1991 this difference had increased reaching its peak equal to 9.2 years).
In women, however, sikness, complains and health impairments which are not directly responsible for death but contribute for example to disabilities, are more frequent than among men. The comparison of data on premature mortality with those reported in other European countries shows that life threats among women are also in contrast to the average situation in the Region.

Areas of residence

At present the average life span of men living in urban areas is longer than of those inhibiting rural areas. On the contrary, women living in rural areas may expect to live longer. Mortality among children over one year of age, adolescents and young men and women is much higher in rural than in urban areas. Rural children aged 1 - 4 are in particularly disadvantegous situation in comparison to their urban peers. The hospitalization rate is lower among rural than urban inhabitants of this age group what may be attributed to differences between the access to hospital treatment. In older age groups mortality rates are higher in towns than among peer groups in rural areas.

Region of residence

Mortality rates differ greatly between different regions (voivodships) of Poland. These differences indicate the varied health status of the population depending on the region of residence. Higher mortality rates and shorter life span are generally observed in western and central parts of the country. The "d+, Wabrzych, Jelenia G"ra, Katowice and Szczecin voivodships belong to most unfavourable regions while people living in the Biaystok and Rzesz"w voivodships enjoy better health condition. In voivodships with the highest mortality rates life threat is increased by 20% in comparison to those with the lowest rates.

Social differences

It is generally observed that in developed countries the health condition of people depends, to a great extent, on their social status. The differences can be seen already at the youngest age. In the groups of the population with the lowest income and education, higher infant mortality rate, slower physical development of children, and higher mortality from most common chronic diseases among blue-collar workers are found. The differences between the social status are also reflected in risk of injuries and poisoning, starting with road traffic casualties through occupational poisoning, suicides and homicides. All these risks are partly related to insufficient knowledge and skills, and health-damaging behaviours, however, none of these shortcomings explain fully the differential impact of social factors.



National Health Programme