Impact of health spending on hospitalization rates in Baltic countries: a comparative analysis.

INTRODUCTION: This study examines the association between healthcare indicators and hospitalization rates in three high-income European countries, namely Estonia, Latvia, and Lithuania, from 2015 to 2020. METHOD: We used a sex-stratified generalized additive model (GAM) to investigate the impact of select healthcare indicators on hospitalization rates, adjusted by general economic status-i.e., gross domestic product (GDP) per capita. RESULTS: Our findings indicate a consistent decline in hospitalization rates over time for all three countries. The proportion of health expenditure spent on hospitals, the number of physicians and nurses, and hospital beds were not statistically significantly associated with hospitalization rates. However, changes in the number of employed medical doctors per 10,000 population were statistically significantly associated with changes of hospitalization rates in the same direction, with the effect being stronger for males. Additionally, higher GDP per capita was associated with increased hospitalization rates for both males and females in all three countries and in all models. CONCLUSIONS: The relationship between healthcare spending and declining hospitalization rates was not statistically significant, suggesting that the healthcare systems may be shifting towards primary care, outpatient care, and on prevention efforts.

Good-Moderate boundary setting for the environmental status assessment of the macrozoobenthos communities with the Benthic Quality Index (BQI) in the south-western Baltic Sea.

The status assessment of the macrofauna community under the European Marine Strategy Framework Directive (MSFD) requires threshold values that mark the transition from good to moderate conditions (G-M boundaries). Using the example of the Benthic Quality Index (BQI) in the south-western Baltic Sea, we demonstrate the possibilities and restrictions of i) defining G-M boundaries using reference areas, historical data and a statistical method and ii) the subsequent evaluation of the resulting G-M boundaries using disturbance data. The historical data from the period 1911 to 1929 proved to be unsuitable for defining G-M boundaries due to their data quality. The G-M boundaries calculated using the statistical method delineated high disturbance values more reliably than those based on reference areas. We conclude that disturbance data are very useful to evaluate G-M boundaries for their suitability, but data on all state conditions are needed.

Educational inequalities in epilepsy mortality in the Baltic countries and Finland in 2000-2015.

Little is known about socioeconomic differences in epilepsy mortality. This study examined educational inequalities in epilepsy mortality in the general population in the Baltic countries and Finland in 2000-2015. Education-specific mortality estimates for individuals aged 30-74 in Estonia, Latvia and Lithuania were obtained from census-linked mortality datasets while data for Finland came from the register-based population and death data file of Statistics Finland. Trends and educational inequalities in epilepsy mortality were assessed using age-standardised mortality rates (ASMRs) per 100,000 person years and age-adjusted mortality rate ratios (RRs) calculated using Poisson regression. ASMRs were higher in men than women in all countries. ASMRs reduced in 2000-2015 among all men and women except for Finnish women. Among men, an inverse educational gradient in epilepsy mortality in 2000-2007 widened in 2008-2015 with ASMRs falling among high and mid educated men in all countries but increasing among low educated men in three countries. An inverse educational gradient in female mortality remained in all countries throughout 2000-2015. Although epilepsy mortality fell in the Baltic countries and Finland (men only) in 2000-2015, this masked a clear inverse educational gradient in mortality that became steeper across the period.

How unnecessarily high abatement costs and unresolved distributional issues undermine nutrient reductions to the Baltic Sea.

This paper systematically reviews the literature on how to reduce nutrient emissions to the Baltic Sea cost-effectively and considerations for allocating these costs fairly among countries. The literature shows conclusively that the reduction targets of the Baltic Sea Action Plan (BSAP) could be achieved at considerably lower cost, if countries would cooperate to implement the least costly abatement plan. Focusing on phosphorus abatement could be prudent as the often recommended measures-wastewater treatment and wetlands-abate nitrogen too. An implication of our review is that the potential for restoring the Baltic Sea to good health is undermined by an abatement strategy that is more costly than necessary and likely to be perceived as unfair by several countries. Neither the BSAP nor the cost-effective solution meet the surveyed criteria for fairness, implying a need for side-payments.

Substances of emerging concern in Baltic Sea water: Review on methodological advances for the environmental assessment and proposal for future monitoring.

The Baltic Sea is among the most polluted seas worldwide. Anthropogenic contaminants are mainly introduced via riverine discharge and atmospheric deposition. Regional and international measures have successfully been employed to reduce concentrations of several legacy contaminants. However, current Baltic Sea monitoring programs do not address compounds of emerging concern. Hence, potentially harmful pharmaceuticals, UV filters, polar pesticides, estrogenic compounds, per- and polyfluoroalkyl substances, or naturally produced algal toxins are not taken into account during the assessment of the state of the Baltic Sea. Herein, we conducted literature searches based on systematic approaches and compiled reported data on these substances in Baltic Sea surface water and on methodological advances for sample processing and chemical as well as effect-based analysis of these analytically challenging marine pollutants. Finally, we provide recommendations for improvement of future contaminant and risk assessment in the Baltic Sea, which revolve around a combination of both chemical and effect-based analyses.

Framework for the environmental impact assessment of operational shipping.

Shipping is an important source of pollution affecting both atmospheric and aquatic environments. To allow for efficient mitigation of environmental degradation, it is essential to know the extent of the impacts of shipping in relation to other sources of pollution. Here, we give a perspective on a holistic approach to studies of the environmental impacts of operational shipping through presentation of an assessment framework developed and applied on a case of shipping in the Baltic Sea. Through transfer of knowledge and concepts, previously used in assessments of air pollution, now applied to assessments of marine pollution and underwater noise, the horizon of understanding of shipping-related impacts is significantly improved. It identifies the main areas of environmental degradation caused by shipping and potential improvements through legislation and technological development. However, as the vast majority of contaminants discharged into the sea are not routinely monitored and assessed, the links between pressure of contaminants from shipping and environmental state and impacts will not be caught in the current environmental regulatory frameworks.

Cost-benefit analysis of beach-cast harvest: Closing land-marine nutrient loops in the Baltic Sea region.

Harvesting beach-cast can help mitigate marine eutrophication by closing land-marine nutrient loops and provide a blue biomass raw material for the bioeconomy. Cost-benefit analysis was applied to harvest activities during 2009-2018 on the island of Gotland in the Baltic Sea, highlighting benefits such as nutrient removal from the marine system and improved recreational opportunities as well as costs of using inputs necessary for harvest. The results indicate that the activities entailed a net gain to society, lending substance to continued funding for harvests on Gotland and assessments of upscaling of harvest activities to other areas in Sweden and elsewhere. The lessons learnt from the considerable harvest experience on Gotland should be utilized for developing concrete guidelines for carrying out sustainable harvest practice, paying due attention to local conditions but also to what can be generalized to a wider national and international context.

Anthropogenic 236U and 233U in the Baltic Sea: Distributions, source terms, and budgets.

The Baltic Sea receives substantial amounts of hazardous substances and nutrients, which accumulate for decades and persistently impair the Baltic ecosystems. With long half-lives and high solubility, anthropogenic uranium isotopes (236U and 233U) are ideal tracers to depict the ocean dynamics in the Baltic Sea and the associated impacts on the fates of contaminants. However, their applications in the Baltic Sea are hampered by the inadequate source-term information. This study reports the first three-dimensional distributions of 236U and 233U in the Baltic Sea (2018-2019) and the first long-term hindcast simulation for reprocessing-derived 236U dispersion in the North-Baltic Sea (1971-2018). Using 233U/236U fingerprints, we distinguish 236U from the nuclear weapon testing and civil nuclear industries, which have comparable contributions (142 ± 13 and 174 ± 40 g) to the 236U inventory in modern Baltic seawater. Budget calculations for 236U inputs since the 1950s indicate that, the major 236U sources in the Baltic Sea are the atmospheric fallouts (∼1.35 kg) and discharges from nuclear reprocessing plants (> 211 g), and there is a continuous sink of 236U to the anoxic sediments (589 ± 43 g). Our findings also indicate that the limited water renewal endows the Baltic Sea a strong "memory effect" retaining aged 236U signals, and the previously unknown 236U in the Baltic Sea is likely attributed to the retention of the mid-1990s' discharges from the nuclear reprocessing plants. Our preliminary results demonstrate the power of 236U-129I dual-tracer in investigating water-mass mixing and estimating water age in the Baltic Sea, and this work provides fundamental knowledge for future 236U tracer studies in the Baltic Sea.

Air pollutants from shipping: Costs of NOx emissions to the Baltic Sea.

Despite a large body of literature on the calculations of costs of air emissions from shipping, calculations of damages to the marine water are missing. This paper calculated the costs of NOx emissions from shipping entering an environmentally heterogeneous sea by applying the abatement cost approach. The total costs and unit shadow cost of NOx were then calculated by means of the marginal abatement cost for international agreements on targets of nitrogen loads to the sea. This conceptual model highlighted the need to distinguish between direct emissions of NOx on the sea and indirect emissions through deposition of emissions on land in the catchment with subsequent transportation into the sea. Calculated total cost amounted to 240 million euros, where indirect deposition accounted for 23% of the costs. The unit shadow costs ranged between 1.41 and 3.69 euros/kg NOx-N depending on location of the vessel.

Baseline assessment of beach cast appearance in the South-Eastern Baltic by video monitoring at a pilot site in the Kaliningrad Oblast (Russia).

A webcam was installed on the shore of the South-Eastern Baltic (Kaliningrad Oblast, Russia) to monitor the beach dynamics and beach-cast (BC) daily from November 1, 2019, to October 31, 2020. The beach was formed not the whole year (77%). The most frequent BC residence time was one day (1-21, 4.1 on average, and 1-19, 4.3 on average days to the west and east of the groin, respectively). The BC consisted primarily of algae. Fresh BC occupied smaller area, and its layer was thicker than that of long-discarded and trampled BC. The specific amount of material (per m2) in a fresh BC was 3.7 times higher in volume and 2.6 times higher in weight than in long-discarded and trampled BC. For fresh and old BC, the specific volumes were 63 and 17 l per m2, respectively, and the specific masses were 48 and 18 kg per m2, respectively.

Increasing the cost-effectiveness of nutrient reduction targets using different spatial scales.

In this paper, we investigate the potential gains in cost-effectiveness from changing the spatial scale at which nutrient reduction targets are set for the Baltic Sea, with particular focus on nutrient loadings from agriculture. The costs of achieving loading reductions are compared across five levels of spatial scale, namely the entire Baltic Sea; the marine basin level; the country level; the watershed level; and the grid square level. A novel highly-disaggregated model, which represents decreases in agricultural profits, changes in root zone N concentrations and transport to the Baltic Sea is used. The model includes 14 Baltic Sea marine basins, 14 countries, 117 watersheds and 19,023 10-by-10 km grid squares. The main result which emerges is that there is a large variation in the total cost of the program depending on the spatial scale of targeting: for example, for a 40% reduction in loads, the costs of a Baltic Sea-wide target is nearly three times lower than targets set at the smallest level of spatial scale (grid square). These results have important implications for both domestic and international policy design for achieving water quality improvements where non-point pollution is a key stressor of water quality.

Shifting networks and mixing metals: Changing metal trade routes to Scandinavia correlate with Neolithic and Bronze Age transformations.

Based on 550 metal analyses, this study sheds decisive light on how the Nordic Bronze Age was founded on metal imports from shifting ore sources associated with altered trade routes. On-and-off presence of copper characterised the Neolithic. At 2100-2000 BC, a continuous rise in the flow of metals to southern Scandinavia begins. First to arrive via the central German Únetician hubs was high-impurity metal from the Austrian Inn Valley and Slovakia; this was complemented by high-tin British metal, enabling early local production of tin bronzes. Increased metal use locally fuelled the leadership competitions visible in the metal-led material culture. The Únetice downfall c.1600 BC resulted for a short period in a raw materials shortage, visible in the reuse of existing stocks, but stimulated direct Nordic access to the Carpathian basin. This new access expedited innovations in metalwork with reliance on chalcopyrite from Slovakia, as well as opening new sources in the eastern Alps, along an eastern route that also conveyed Baltic amber as far as the Aegean. British metal plays a central role during this period. Finally, from c.1500 BC, when British copper imports ceased, the predominance of novel northern Italian copper coincides with the full establishment of the NBA and highlights a western route, connecting the NBA with the southern German Tumulus culture and the first transalpine amber traffic.

Seasonal variability, long-term distribution (2001-2014), and risk assessment of polar organic micropollutants in the Baltic Sea.

From 2001 to 2014, 13 surveys were conducted in the Baltic Sea, to determine its pollution of 50 micropollutants. The investigations focused mostly on the German western Baltic Sea; in 2008, one survey covered the entire Baltic Sea. Various groups of herbicides (such as triazines, phenoxyacetic acid, phenylurea), perfluoroalkyl substances, pharmaceuticals, and industrial products were analyzed during these surveys. The highest concentrations (median 1 to 4 ng/L) were observed for atrazine, simazine, chloridazone, 2,4-dichlorophenoxyacetic acid, benzotriazole, primidone, and carbamazepine. Most micropollutants exhibited a relatively homogenous spatial distribution, though some herbicides show elevated concentrations in certain regions (e.g., Odra estuary), indicating a riverine input. The data set was analyzed, both for seasonal influences and long-time trends. Some herbicides exhibited higher concentrations during summertime. Both upward- and downward-directed time trends could be identified for some herbicides and perfluorinated compounds. For most of the detected compounds, a low-risk quotient was calculated. Only the occurrence of carbendazim could potentially pose a higher risk to the Baltic Sea.

Assessing the costs and environmental benefits of IMO regulations of ship-originated SOx and NOx emissions in the Baltic Sea.

To assess the value of the environmental benefits of the Sulphur Emission regulation (SECA) that came into force in 2015, changes in depositions of SOx and NOx from ship exhaust gas emissions were modelled and monetized for the Baltic Sea region for the years 2014 and 2016. During this period, the total deposition of SOx in the study area decreased by 7.3%. The decrease in ship-originated SOx deposition from 38 kt to 3.4 kt (by over 88%) was translated into a monetary value for the ecosystem impacts of nearly 130 million USD, according to the EcoValue08 model. This is less than the modelled health benefits, but it is not insignificant. For NOx, there was no decreasing trend. The exceedance of the critical loads of SOx and NOx was also estimated. The effect of Baltic shipping on the exceedance of critical loads of acidification after SECA is very small, but Baltic shipping still has a considerable effect on the exceedance of critical loads for eutrophication.

Valuating environmental impacts from ship emissions - The marine perspective.

Shipping is an activity responsible for a range of different pressures affecting the marine environment, air quality and human welfare. The methodology on how ship emissions impact air quality and human health are comparatively well established and used in cost-benefit analysis of policy proposals. However, the knowledge base is not the same for impacts on the marine environment and a coherent environmental and socio-economic impact assessment of shipping has not yet been made. This risk policies to be biased towards air pollution whilst trading off impacts on the marine environment. The aim of the current study was to develop a comprehensive framework on how different pressures from shipping degrade marine ecosystems, air quality and human welfare. A secondary aim was to quantify the societal damage costs of shipping due to the degradation of human welfare in a Baltic Sea case study. By adding knowledge from marine ecotoxicology and life-cycle analysis to the existing knowledge from climate, air pollution and environmental economics we were able to establish a more comprehensive conceptual framework that allows for valuation of environmental impacts from shipping, but it still omits economic values for biological pollution, littering and underwater noise. The results for the Baltic Sea case showed the total annual damage costs of Baltic Sea shipping to be 2.9 billion €2010 (95% CI 2.0-3.9 billion €2010). The damage costs due to impacts on marine eutrophication (768 million €2010) and marine ecotoxicity (582 million €2010) were in the same range as the total damage costs associated with reduced air quality (816 million €2010) and climate change (737 million €2010). The framework and the results from the current study can be used in future socio-economic assessments of ship emissions to prioritize cost efficient measures. The framework can be used globally but the damage costs presented on the marine environment are restricted to emissions on the Baltic Sea and Kattegat region as they are based on willingness to pay studies conducted on citizens around the Baltic Sea where eutrophication and emissions of chemicals are particularly threats to the state of the Baltic Sea.

Economic fluctuations and urban-rural differences in educational inequalities in mortality in the Baltic countries and Finland in 2000-2015: a register-based study.

We examined urban-rural differences in educational inequalities in mortality in the Baltic countries (Estonia, Latvia, Lithuania) and Finland in the context of macroeconomic changes. Educational inequalities among 30-74 year olds were examined in 2000-2003, 2004-2007, 2008-2011 and 2012-2015 using census-linked longitudinal mortality data. We estimated age-standardized mortality rates and the relative and slope index of inequality. Overall mortality rates were larger in rural areas except among Finnish women. Relative educational inequalities in mortality were often larger in urban areas among men but in rural areas among women. Absolute inequalities were mostly larger in rural areas excepting Finnish men. Between 2000-2003 and 2012-2015 relative inequalities increased in most countries while absolute inequalities decreased except in Lithuania. In the Baltic countries the changes in both relative and absolute inequalities tended to be more favorable in urban areas; in Finland they were more favorable in rural areas. The overall pattern changed during the reccessionary period from 2004-2007 to 2008-2011 when relative inequalities often diminished or the increase slowed, while the decrease in absolute inequalities accelerated with larger improvements observed in urban areas. Despite substantial progress in reducing overall mortality rates in both urban and rural areas in all countries, low educated men and women in rural areas in the Baltic countries are becoming increasingly disadvantaged in terms of mortality reduction.

High resolution model for assessment of contamination by chemical warfare agents dumped in the Baltic Sea.

The leakage of any substances at the sea bottom consequently leads to contamination. The polluted area will strongly depend on the type of pollution which can be dissolved, material and the physical state of the bottom layers. Although the systems that monitor the particles or pollution on the sea surface already exists, there is no similar tool for the bottom area. This work aims at developing the High Resolution Dispersion Model (HRDM) that calculates transport of the pollution in case of potential leakage from chemical ammunition dumped into the Baltic Sea. The model has been embedded into existing operational system that covers the whole region of the Baltic Sea. Thus, it consists of the three main elements: operational atmospheric model that makes calculations every day, coupled ice-ocean model covering the whole Baltic Sea area and HRDM. The horizontal resolution of the atmospheric part is about 10 km, the coupled system is driven on 2.3 km grid and HRDM is implemented on 50 m horizontal resolution. The clients are able to make integration since 2014. Access to the system is granted via REpresentational State Transfer (REST) API that separates user interface from the server site. It is possible to make simulations for instantaneous and continuous type of leakage. The results are served in binary form (as a netcdf file) and as a georeferenced tiff picture. The temporal resolution of the output data is 1 h. The HRDM consists of half-life of sulfur mustard and the results for both - with and without half-life calculations are included in the output files. The HRDM has been created as a part of Decision Support System and is not (and will not be) available for public.

Developing improved methods for identifying the cost-efficient abatement set in coastal water quality protection.

Eutrophication of coastal waters is a recognised problem in estuaries around the globe. To analyse cross-boundary water quality management, such as protection of the Baltic Sea, economic nutrient abatement models commonly operate on a large scale, grouping river systems to large catchment areas. Theoretical deliberation suggests that modelling abatement in such a way removes the opportunity of targeting measures to the most vulnerable regions within the catchment, while overestimating the capacity of abatement measures in the upstream areas. However, the implications on designing environmental policy depend on catchment characteristics and the stringency of the abatement targets. In this study a model of the catchment area is built with zones that are an increasing distance away from the coast to show what kind of bias in the optimal abatement set is caused by the assumption of spatial homogeneity. By solving the model with and without the zones for good ecological status at the South-West coast of Sweden, it is shown that while assuming homogeneity prevents from perceiving the abatement measures where they would be the most effective, it also leads to ignoring spatial limitations that are more relevant to a subset of abatement measures, such as the wetlands and buffer zones. Following from the relatively large nitrogen abatement targets, the overall effect of assuming catchment homogeneity is to underestimate the abatement costs and to overestimate the potential of wetlands to reduce nitrogen.

Evolution of External Health Costs of Electricity Generation in the Baltic States.

Implementation of strict policies for mitigating climate change has a direct impact on public health as far as the external health costs of electricity generation can be reduced, thanks to the reduction of emission of typical pollutants by switching to cleaner low carbon fuels and achieving energy efficiency improvements. Renewables have lower external health costs due to the lower life cycle emission of typical air pollutants linked to electricity generation, such as SO2, NOx, particulate matter, NH3, or NMVOC (Non-methane volatile organic compounds), which all appear to have serious negative effects on human health. Our case study performed in the Baltic States analyzed the dynamics of external health costs in parallel with the dynamics of the main health indicators in these countries: life expectancy at birth, mortality rates, healthy life years, self-perceived health, and illness indicators. We employed the data for external health costs retrieved from the CASES database, as well as the health statistics data compiled from the EUROSTAT database. The time range of the study was 2010-2018 due to the availability of consistent health indicators for the EU Member States. Our results show that the decrease of external health costs had a positive impact on the increase of the self-perceived good health and reduction of long-standing illness as well as the decrease of infant death rate. Our conclusions might be useful for other countries as well as for understanding the additional benefits of climate change mitigation policies and tracking their positive health impacts. The cooperation initiatives on clean energy and climate change mitigation between countries like One Belt One Road initiative by the Chinese government can also yield additional benefits linked to the public health improvements.

Zooplankton indicator-based assessment in relation to site location and abiotic factors: a case study from the Gulf of Riga.

There are a number of zooplankton parameters proposed as indicators to evaluate environmental status of marine ecosystems. Mean size and total stock (MSTS) is the only zooplankton-based and HELCOM (Baltic Marine Environment Protection Commission - Helsinki Commission)-approved core indicator. MSTS was developed to evaluate the environmental status of the Baltic Sea based on total biomass (or abundance) and mean body weight of mesozooplankton. This indicator reflects status of the food web and zooplankton biodiversity. Both are qualitative descriptors for determining good environmental status (GES) as defined by the EU Marine Strategy Framework Directive 2008/56/EC. However, the existing indicator concept is applicable to the extent that it characterizes off-shore pelagic habitats, while use of MSTS for coastal habitats remains challenging. In this case study, we aimed to assess and discuss performance of MSTS applied to mesozooplankton data from the shallow Gulf of Riga. Both off-shore and coastal communities were included in the study. MSTS responses to variable environmental factors (temperature, salinity and riverine runoff) were analysed. Temporal variations in temperature revealed response in mean size, whereas salinity covaried with total stock (both - biomass and abundance). However, spatial variations of MSTS parameters stayed unexplained. The results demonstrate difficulties with and provide possible solutions for MSTS-based assessment, with a particular emphasis on coastal waters. The use of mesozooplankton abundance as a determinant parameter for assessment of coastal waters and substitution of the corresponding 99% confidence interval of the mean as an assessment value instead of the mean have been considered.