The German Energiewende
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The European Journal of Public Health, Vol. 26, No. 4, 707–712
The Author 2015. Published by Oxford University Press on behalf of the European Public Health Association. All rights reserved.
doi:10.1093/eurpub/ckv212 Advance Access published on 29 December 2015
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The German Energiewende—a matter for health?
Robynne Sutcliffe, Ester Orban, Kelsey McDonald, Susanne Moebus
Centre for Urban Epidemiology, Institute for Medical Informatics, Biometry and Epidemiology, University Hospital of
Essen, University of Duisburg-Essen, Germany
Correspondence: Robynne Sutcliffe, Centre for Urban Epidemiology, Institute for Medical Informatics, Biometry and
Epidemiology, University Hospital of Essen, University of Duisburg-Essen, Hufelandstraße 55, 45147 Essen, Germany,
e-mail: [email protected], Tel: +49 201 92239 291, Fax: +49 201 92239 333
Background: Germany’s enormous transformation away from nuclear energy and fossil fuels towards a renewable
and energy efficient system—called the Energiewende—is playing an essential role in Germany’s economy and
policymaking. This article summarises the current knowledge on possible health impacts of the Energiewende and
describes the need and opportunities to incorporate health into energy-related policy. Methods: A structural
model helped to narrow down specific topics and to conceptualise links between the Energiewende, the environment and health. A comprehensive literature search was conducted within policy documents and scientific
databases with English and German language selections. Results: Of 7800 publications first identified only 46
explicitly related energy measures to health, of which 40 were grey literature. Notably, only 12% published by
health authorities all others were issued by environmental, energy or consumer protection agencies, ministries or
institutions. Conclusion: Our study shows that health impacts of the German Energiewende are rarely explicitly
addressed. An integration of a health perspective into energy-related policy is needed including the involvement
of public health authorities. A health impact assessment can be a suitable tool to support and evaluate
Energiewende-related developments from a health perspective.
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Introduction
As evidence of the harmful effects of climate change has
accumulated, Germany—on its own and as part of the European
Union (EU)—is actively implementing mitigation strategies. The
debate on climate change and the rising evidence that mitigation
strategies are needed to reduce greenhouse gas (GHG) emissions and
other climate altering pollutants1,2 led to a EU agreement on climate
and energy-related policy action. The EU established a binding
commitment to reduce emissions by 2020, to raise the share of EU
renewable energy consumption and to improve the EU’s energy efficiency.3 In 2000, the German Federal Government implemented
the Renewable Energy Sources Act (EEG), which remains the
principle tool for managing and commissioning the renewable
energy sector in Germany (last renewed in 2014).4 After the
Fukushima disaster in 2011, the German government immediately
shut down eight nuclear power plants in the country, nearly a third
of Germany’s nuclear power capacity. This prompted the
Energiewende. Germany’s enormous energy transformation is more
than just a nuclear energy exit. The Energiewende is a complex
restructuring of Germany’s energy system by expanding renewable
energy and increasing energy efficiency to replace fossil fuels and
nuclear power.
The main targets within the Energiewende are to:5,6
reduce GHG emissions by 40% by 2020,
increase the share of renewables in energy consumption and
gross electricity production = to 60 and 80%, respectively, by
2050 and
decrease primary energy consumption by 50% by 2050.
Meeting these ambitious targets will have profound impacts on
Germany’s energy supply, infrastructure, economy and technology.
Despite expansion of the wind, photovoltaic (PV) and biomass
sectors during the last 13 years,5 as well as previous measures to
improve energy efficiency, Germany must implement additional
measures and technologies across many sectors to achieve its
goals. For example, the Energiewende not only sets out high
energy-efficiency standards for newly constructed buildings but
also calls for complete refurbishment of old houses and buildings.
Another approach to increase energy efficiency is to promote clean
vehicles within the transport sector, most commonly known as
electric and hybrid vehicles (EVs). The plan set out by the
German government is to introduce 1 million electric cars by 2020
on German roads.5,6
As Energiewende policy is not implemented by health authorities,
the link between the Energiewende and health may not be immediately clear; nevertheless the public health implications of energyrelated changes are important to consider. Energy-related research
has shown that renewable energy systems and energy efficient
measures may provide opportunities to improve public health.7,8
For example, estimates suggest that switching to a cleaner energy
system will reduce emissions of carbon dioxide (CO2) and other
climate altering pollutants,1,2 thus ensuring several co-benefits for
human health.8,9 Furthermore, by decreasing carbon intensity of
electricity generation as well as by enhancing energy efficiency,
emissions can be reduced and consequently some of the possible
health burden from air pollution. Energy efficient transportation
can also lead to changes in mobility demand and mode, inducing
possible beneficial behavioural changes and decreased noise and air
pollution. Refurbishment of houses into energy efficient buildings
may improve health in cold winters by also protecting against mould
and dampness.8,10–13 It is also important to acknowledge the
potential for negative effects of these energy-related changes on
health. For example, low carbon systems have to be maintained
otherwise they can impose possible health risks on the population.8
In short, switching to a cleaner energy system will not only affect
global climate change2 but also may have profound impacts on
population health at the local level.9
Therefore, this research addresses the Energiewende, its corresponding changes and its possible effects on health either positive or negative.
Without a doubt the German Energiewende and its rapid changes are
affecting all sectors of society.5,6 Therefore, it is necessary to
(1) analyse if health impacts are considered in the Energiewende and
if so to what extent,
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European Journal of Public Health
(2) summarise the current knowledge on possible energy-related
health impacts and
(3) highlight the needs and opportunities to incorporate health into
energy-related policy.
Methods
A structural model (figure 1) based on the WHO Driving forces,
Pressure, State, Exposure, Effect and Action (DPSEEA) framework14
helped define the scope of our research. The DPSEEA model allowed
us to conceptualise links between the Energiewende, the environment
and health to detect and prioritise the topics and key words for the
literature search (figure 1). Key words which were used for the
literature search are provided in bold in figure 1: renewable
energy, energy efficiency, conservation of energy resources, energy
production, recycling, transport, biomass, environment, health.
A comprehensive literature search was conducted within scientific
databases and policy documents (grey literature) between July and
October 2013 with English and German language selections.
Literature published before 2000 was excluded since the
Energiewende was not introduced until then. We also distinguished
between explicit/implicit connections to health within the literature.
Explicit connection means that there is a clear formulated reference
made to health outcomes, effects or health problems, whereas an
implicit connection to health suggests logical consideration within
the literature. Figure 2 represents an overview of the identified
literature.
Scientific databases
A literature search was conducted in PubMed, the Thomson Reuters
Web of Knowledge, Scopus and Cochrane using combinations of
terms for energy-related topics and selected health topics
(as detailed later). MeSH Terms were used where relevant. Title
and/or abstracts were reviewed. The inclusion criterion was that a
significant pressure-state-exposure chain as seen in figure 1 was represented in the literature. Ideally this chain also included an explicit
connection between exposure and health effect; however, literature
with more implicit connections were also included. Key terms that
helped to identify the literature were: emission and/or exposure,
environment, health, human and/or impact.
Grey literature
The literature search also included reports, guidelines, reviews,
handbooks, brochures, leaflets and website texts (grey literature)
from governmental and non-governmental institutions and organisations. Online databases from German ministries and agencies,
both federal and state, as well as international agencies and organisations were searched. The search was not confined conventionally
to search algorithms but rather to themes of Energiewende-related
policy topics: energy transition, renewable energy, energy efficiency,
resource, raw material, waste, recycling, transport/mobility, (built)
environment, (indoor) air quality. Literature was identified on the
basis of title, table of contents and abstracts. Publications were
excluded if they did not address energy and resource policy topics
in relation to health and/or environment. Special key words
included: emission and/or exposure, environment, health, human
and/or impact.
Results
Of more than 7800 publications first identified, 72 publications (21
scientific studies, 19 reviews, 32 reports) were considered as relevant
(figure 2), of which 46 explicitly related energy measures to health.
Notably, 40 of the 46 publications came from grey literature, the vast
majority (88%) stemming from environmental, energy or consumer
protection agencies, ministries or institutions and only 12% being
Acon
Driving
Forces
Pressure
State
Exposure
Health
Effect
ENERGIEWENDE
Social policy
Economic policy
Climate change
migaon
Changes in energy and resource
policy and nuclear power exit
Energy producon/
generaon
e.g. wind, solar, dal,
biomass, …
Energy consumpon/
efficiency
e.g. materials, covers and
paints in houses, insulaon,
energy saving light bulbs, …
Physical Environment
Built Environment
Biodiversity, Polluon to
air, water, soil
Buildings, Indoor climate,
Mobility and transport
Transport and Mobility
e.g. electric vehicles, …
Occupaonal
Environment
Occupaonal hazards,
Mechanical processes
Waste
e.g. recycling, raw
materials, …
Socio-economic
Environment
Producon control
Emission control
Waste control
Clean technology
Environmental
improvement
Employment,
Environmental jusce,
Educaon
Environmental Exposure (dose)
Educaon,
Awareness
Exposure and suscepbility to (Air, water, soil) polluon, mould/dampness, noise/infrasound, injuries
Health outcome
Physical, mental and social well-being
Figure 1 The Energiewende and health according to the DPSEEA framework (adapted from Corvolán et al. 200014)
Treatment
The German Energiewende
709
7,817 records overall idenfied
629 records through grey literature searching
7,188 records through scienfic database searching
Excluded
(n= 350)
Excluded records
(n= 6,999)
Title, Keyword and
Abstract screen
(n= 279)
Title and keyword
screen
(n=189)
Excluded
(n= 244)
Excluded records
(n=160)
Abstract screen
and full text review
(n=29)
Full text review
(n= 35)
8 records through hand
searching
72 records finally included
Figure 2 Flow diagram for literature search
commissioned and issued by health authorities. Up to this point it
appears from our research that the public health scientific
community have had limited involvement in setting Energiewende
policy in Germany, whilst the relatively few public health considerations have been driven by environmental agencies.
The literature search showed that energy-related research and specifically Energiewende-related research have focussed on evaluating
key environmental impacts from specific energy sources, which are
commonly based on a life cycle assessment (LCA). This tool is a
‘technique to assess the environmental aspects and potential impacts
associated with a product or process (p.2)’,15 including ‘evaluation
of possible hazards in each life cycle stage and/or major contributing
process (p.3)’.15 Possible emissions to air, soil and water are
calculated and external costs, such as economic, occupational and
to some extent social impacts, are assessed.16 Although LCAs are a
useful tool to understand health-related outcomes, health impacts
were not always analysed explicitly within the identified literature
using LCA.
Overall, we found few explicit or implicit connections to health
referenced in the Energiewende literature. Yet even in these relatively
few references, we found potential positive and negative effects of the
Energiewende on health. In the following paragraphs, key findings
from the literature search are thematically summarised and
presented. If possible specific health considerations or energyrelated interventions for the German context are given as examples.
Electricity generation from renewable energy sources
LCA shows that manufacturing emissions are of concern to health.
For example, the production and recycling of PV panels may
exposure people to toxic metals and chemical processes,17–19 the
potential effects of which are still uncertain as PVs are relatively
new.20 In regard to wind energy, the literature identified focuses
particularly on health concerns from noise and infrasound levels
as well as the production of shadow flickers or possible ice
throw.21–24 The research in regard to wind energy is mainly
interested in possible noise related sleep disturbances, stress and
the reduction in quality of life.21–24 In Germany, appropriate
guidelines have already been implemented that reduce the possible
negative health impacts from wind energy such as proximity to
neighbourhood and duration of rotation.
Bioenergy
Switching to wood-fired heating systems (on district scale or inhome heating) can reduce GHG emissions (CO2).25,26 However,
wood combustion for direct heat use can be a major contributing
source of fine particulate matter (black carbon, organic carbon) in
urban areas and in indoor buildings,25 something which is known to
be relevant for climate and health. The WHO reports that particulate
matter (PM) from biomass can be associated with certain adverse
health effects such as effects on the respiratory and possibly also on
the cardiac system.27,28 In 2010, Germany introduced new regulations that considered appropriate standards (lower threshold of
emissions) and requirements (in production, quality, use and maintenance) for such heating systems, especially for older models to
reduce the possible adverse health effects.29,30
The use of bioethanol and biodiesel, as compared with traditional
diesel and fossil fuels, reduces CO2 emissions;26 however, the use of
those fuels to reduce harmful emissions remains controversial, as
exposure to certain chemicals is still possible, especially during
biochemical processes. The use of pesticides and fertilisers during
cultivation may damage soil, air, water and biodiversity. Other
concerns include the effects of sustainable forestry during the cultivation, origin and transportation of wood or crops and biological
materials.31
Energy efficiency via the built environment
Energy efficient homes can improve the indoor climate,32 and
thereby may improve mental and psychosocial wellbeing.12
Furthermore, better insulation measures reduce the exposure to
outside pollutants and prevent moisture accumulation that may
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European Journal of Public Health
lead to mould growth.33 However, better insulation also requires
regular control of ventilation, as reduced air exchange has the
potential to cause an undesired increase in exposure to indoor pollutants.8,10,12 Energy efficiency in housing has become one of the
major pillars of the Energiewende, which has lead to not only the
refurbishment of old buildings and the introduction of energy
efficient heating systems, but also to an increase in standards for
newly constructed buildings, especially public buildings.
Furthermore, strong focus has been given on guidelines to inform
the public about ventilation within their homes.
Transport, mobility and EVs
A central feature of EVs is that they are virtually emission free at
local level, with the exception of minor emissions from brake and
tire abrasion. A further advantage of EVs is that they are possibly
quieter and thus reduce noise levels in areas with low speed levels.
However, this depends on the type of vehicle.34 Recent discourse
about EVs has discussed the potential for increased risk of
pedestrian and cyclist accidents and injuries due to the missing
noise of approaching vehicles. Empirical data for this aspect do
not exist yet.34 A review by Thomson et al.35 (p. 1) demonstrated
that the ‘health impact assessment (HIA) of transport interventions
is still characterised by uncertainty and competing values at local or
wider level’.
Recycling
With regard to renewable and energy-saving technologies, the
impact of extraction and supply of critical raw materials together
with thier waste management are of concern. During extraction and
the processing of critical resources (burning of waste) possible toxic
and harmful pollutants can be released into air, soil and water.36,37
The impacts of current and future recycling procedures are still
difficult to assess due to lack of data and inadequate experience—
especially with regard to health-related issues and occupational
safety requirements.
Discussion
From our literature search, we observed that possible health benefits
and risks are rarely explicitly, if at all, considered within the
discourse of the German Energiewende. Although it appears that
most Energiwende-related measures were driven by environmental
concerns, it should not be neglected that this inevitably can have an
impact on the health of the population. Nevertheless, the link to
health is often not clarified within the identified literature, except
for those specific energy-related measures that were summarised
earlier and that specifically considered health effects. A reason for
this may include the difficulty of estimating possible health impacts
within such complex settings. Still, extensive peer-reviewed epidemiological evidence links health effects to certain concentrations
of pollution13 or environmental exposures. From the evidence
available, it is possible to extrapolate potential impacts on human
health. In most cases within the Energiewende literature, this
reference is missing; only environmental effects are described
without any classification or characterisation of possible consequences for health, either positive or negative.
A further rationale for the lack of explicit attention to health in
the Energiewende emerged from our research. It appears as if the
public health scientific community have had limited involvement in
setting Energiewende policy in Germany, whereas the relatively few
public health considerations have been driven by environmental
agencies. This may arise due to the fact that public health authorities
in Germany are not involved in the implementation of Energiewende
policy, although some public health professionals are actively
engaged in internal Energiewende-related discussions. As a result
energy-related health impacts are still not sufficiently considered
in the development of Energiewende measures and technologies.38
Our results suggest the need for a thorough examination of
possible public health effects of the expanding renewable energy
sector and the development of further technological improvements.
Thus, public health authorities and the German public health
scientific community should be involved more in the question of
possible health impacts. These impacts may originate not only from
environmental but also economic, social and occupational issues.
Importantly, a thorough examination of the Energiewende
health effects should highlight not only health risks but also
health benefits arising from the emerging energy-related
technologies.
In this regard, public health professionals could use a HIA tool
for evaluation of the Energiewende and its individual measures and
future technological developments on public health. The WHO
(1999) defines a HIA as ‘a combination of procedures, methods
and tools by which a policy, programme or project may be
judged as to its potential effects on the health of a population,
and the distribution of those effects within the population’.38 A
HIA not only measures health impacts in terms of quantitative
data but also qualitatively, considering important participatory
aspects. Integrating a HIA into current energy policy decisions
can provide a systematic comparison of energy options from a
health perspective.38 For example, HIA can help to identify the
possible determinants of health, which are to some extent affected
by energy-related decisions, such as technological development,
transport and housing. At the same time, it helps disseminate
information and knowledge to the population who can then
implement healthy behaviours in terms of energy efficiency and
sustainable living.
Furthermore, HIA can facilitate cooperation and those synergies
between public health authorities and other Energiewende-related
sectors which are currently lacking. The Energiewende is a crosscutting issue affecting many sectors within German policymaking;
therefore, existing tools such as HIA can help to bring together
different sectors.38
Germany’s Energiewende is a unique and historic transition to a
highly efficient energy system, which has been recognised not only
nationally but also internationally. Transforming a major economy
to a more efficient energy system is a step forward to reduce GHG
emissions and possible adverse health consequences of climate
change. As other countries especially in the European Region
consider energy-related changes, the Energiewende provides
important information on possible effects, including those on
health.
By getting directly involved in the Energiewende discourse, public
health authorities can seize the opportunity to help shape policies
that may have a large-scale impact on population health. Public
health authorities and professionals can also provide people with
concrete information on possible health benefits and risks in
regard to specific Energiewende-related measures and technologies.
Although our understanding of some of the Energiewende-related
measures and technologies and their potential effects on
health is still developing and may be difficult to assess, the
health effects should be evaluated and integrated into energyrelated policy.
Funding
The literature study underlying this article was supported with
funding from the German Federal Environment Agency
(Umweltbundesamt). The responsibility for the content of this publication lies with the authors.
The work was also presented at the 11th International Conference
for Urban Health, Manchester, 4–7 March 2014 and at the German
The German Energiewende
Society for Social Medicine and Prevention (DGSMP) in Erlangen,
Germany, 23–26 September 2014.
Conflicts of interest: None declared.
Key points
Direct impacts of the Energiewende on health are relatively
unexamined.
Further involvement by the public health community within
the Energiewende is urgently needed.
Life cycle assessment (LCA) is a useful tool to examine
possible emissions to air, soil and water but rarely leads to
explicit examination of health impacts
Health impact assessments (HIA) can help to inform energyrelated policy decisions that are attentive to public health
711
14 Corvolán C, Briggs D, Zielhuis G. (eds.) on behalf of the World Health Organization
Decision-Making in Environment Health: From Evidence to Action. E&FN Spoon,
London and New York 2000.
15 Environmental Protection Agency. US EPA Life Cycle Assessment: Principles and
Practice. Available at: http://www.epa.gov/research/NRMRL/std/lca/pdfs/chapter1_
frontmatter_lca101.pdf (27 February 2014, date last accessed).
16 Joint Research Centre. The International Reference Life Cycle Data System
(ILCD) Handbook (online version). Available at: http://eplca.jrc.ec.europa.eu/
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17 Bavarian Environment Agency (LFU). Berechnung von Immissionen beim Brand einer
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19 Fthenakis VM, Moskowitz PD. Photovoltaics: environmental, health and safety
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The European Journal of Public Health, Vol. 26, No. 4, 712–717
The Author 2015. Published by Oxford University Press on behalf of the European Public Health Association. All rights reserved.
doi:10.1093/eurpub/ckv217 Advance Access published on 3 December 2015
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Mortality in Italian veterans deployed in
Bosnia–Herzegovina and Kosovo
Riccardo Capocaccia1, Roberto Biselli2, Raffaella Ruggeri1,2, Cristiano Tesei1,2, Enrico Grande1,
Lucia Martina1, Anna Rocchetti2, Stefania Salmaso1, Massimiliano Caldora1, Silvia Francisci1
1 Cancer Epidemiology Unit, National Center of Epidemiology, Istituto Superiore di Sanità, Rome, Italy
2 Italian Defence General Staff, General Inspectorate of the Military Health Service, Rome, Italy
Correspondence: Riccardo Capocaccia, Cancer Epidemiology Unit, National Center of Epidemiology, Istituto Superiore di
Sanità, Rome, Italy, e-mail: [email protected]
Background and Aims: The possible increase of cancer risk in military personnel deployed in Balkans during and
after the 1992–1999 wars, mainly related to the depleted uranium, was addressed by several studies on European
veterans of those war theatres. This article reports on the results of the mortality study on the Italian cohort of
Bosnia and Kosovo veterans (Balkan cohort). Methods: Mortality rates for the Balkan cohort (71 144 persons) were
compared with those of the Italian general population as well as to those of a comparable and unselected control
cohort of not deployed military personnel (114 269 persons). Ascertainment of vital status during the period 1995–
2008 of all the persons in the two cohorts has been carried out through deterministic record linkage with the
national death records database, from information provided by the respective Armed Force General Staff, and
through the civil registry offices of the veterans’ residence or birth municipalities. Results: The Balkan cohort
experienced a mortality rates lower than both the general population (SMR = 0.56; 95% CI 0.51–0.62) and the
control group (SMR = 0.88; 95% CI 0.79–0.97). Cancer mortality in the deployed cohort group was half of that from
the general population mortality rates (SMR = 0.50; 95% CI 0.40–0.62) and slightly lower if compared with the
control group cancer mortality rates (SMR = 0.95; 95% CI 0.77–1.18). Conclusion: Balkan veteran cohort did not
show any increase in general mortality or in cancer mortality.
.........................................................................................................
Introduction
he presence of an increased cancer risk in military personnel
Tdeployed in Balkans during and after the 1992–1999 wars has
been widely debated, mainly related to the depleted uranium (DU)
enforced projectiles used on the battlefields. There is a general
consensus that inhalation of impact aerosol and dust in target
areas represents the most significant route of exposure.1 The
hazard is attributable to either the chemical toxicity of the metal
and the internal exposure to alpha and beta radioactivity in body
tissues.2,3 Lung cancers, leukaemias and lymphomas are the cancer
types expected to be most likely associated with this kind of
exposure.4
As a consequence of the public concern, specific studies to
evaluate an excess cancer risk in military personnel deployed in
war theatres during the 1990s and 2000s have been carried out,
first on US and UK veterans of the Gulf war,5–14 and then on UK,
Swedish, Danish, Canadian, Italian, Dutch and Norwegian peacekeeping soldiers deployed in the Balkans region.14–19 Italian
Armed Forces have been massively involved since the year 1995 in
peace restoring and peace keeping operations in Bosnia and Kosovo.
A committee appointed by the Italian Ministry of Defence
reported20 a significant excess of Hodgkin Lymphoma cases
diagnosed in the period 1996–2001, and no increased risk for
other cancers.
The longitudinal Bosnia Kosovo (BK) Study has been started in
2005, through a collaboration between the Italian General
Directorate of Military Health, the Italian Ministry of Health and
the National Institute of Health,21 to describe the health profile of
the Italian veterans cohort deployed in Bosnia and Kosovo (Balkan