Breast cancer incidence, asthma, and a high prevalence of preterm births. These are the three most common conditions among the population of the Campania region known as the "Land of Fires," as revealed in the first three years of the study on the health impact of waste disposal and combustion conducted by the National Institute of Health (ISS) on behalf of the Naples North Prosecutor's Office for municipalities between the provinces of Naples and Caserta, within the jurisdiction of the Aversa Prosecutor's Office. The data was released by Prosecutor Francesco Greco, who specified that the study has not yet been able to uncover a causal link between environmental pollution and disease, but rather a correlation. "From this data," Greco explained, "we can begin to explore both how to address them from a legal perspective and to form a pool of magistrates to focus exclusively on cleanup." The study covered an area of 38 municipalities with a population of approximately one million people and affected by the presence of 2767 controlled or illegal waste disposal sites, 653 of which also reportedly involved illegal burning. The municipalities were divided into four classes, from first to fourth, with increasing risk ratings; the highest rating, 4, was assigned to the Giugliano and Caivano areas.
1) The health risk of the resident population was the first objective of the investigation. To this end, each site was assigned a hazard index that takes into account the nature of the waste, the characteristics of the area, the amount of material disposed of and the potential contamination methods of air, soil and ground and surface water. The sites under examination were then mapped on the territory of the 38 municipalities of the District, and for each Municipality the percentage of the population residing in the “impact area” was estimated, with a radius of 100 m around each site. The model used (based on the study “The impact measure of solid waste management on health: the hazard index” by L. Musmeci, M. Bellino, MR Cicero, F. Falleni, A. Piccardi and S. Trinca. Annali ISS (2010) Vol. 46, No. 3: 293-298) takes into account the fact that the impact areas of the different sites may overlap. From this database, a waste exposure indicator was finally calculated for each Municipality, which takes into account the dangerousness of the sites present in the municipal territory and the percentage of the population residing in their respective impact areas. Based on the value of this indicator, the municipalities were divided into four classes of increasing value; in the analyses, the municipalities of the first class were used as the reference population.
2) In the municipalities of the area under examination, it is estimated that 354.845 inhabitants, equal to 37% of the population, live within 100 meters of at least one site, but often more than one, and this determines a multiplicity of dangerous sources of exposure.
3) Considering the health indicators, in the area under examination, and in most of the individual municipalities, excess mortality (period 2008-2015) and incidence (2008-2012) are observed in both genders for all tumors, taking as reference population, respectively, the population resident in the Campania Region, (data on mortality and hospitalization by cause are available for all Italian municipalities), and the population resident in the areas of Southern Italy served by Tumor Registries accredited by the Italian Association of Tumor Registries, AIRTUM. The latter was used as reference population in the analysis of tumor pathologies, as there is not yet an exhaustive coverage of the regional territory by the Registries themselves, and therefore it is not possible at the moment to estimate the "expected" cases on a regional basis.
3) Considering the health indicators, in the area under examination, and in most of the individual municipalities, excess mortality (period 2008-2015) and incidence (2008-2012) are observed in both genders for all tumors, taking as reference population, respectively, the population resident in the Campania Region, (data on mortality and hospitalization by cause are available for all Italian municipalities), and the population resident in the areas of Southern Italy served by Tumor Registries accredited by the Italian Association of Tumor Registries, AIRTUM. The latter was used as reference population in the analysis of tumor pathologies, as there is not yet an exhaustive coverage of the regional territory by the Registries themselves, and therefore it is not possible at the moment to estimate the "expected" cases on a regional basis.
4) Among the tumors for which there is evidence in the scientific literature of an association with exposure to uncontrolled hazardous waste disposal sites that can be defined as at least “limited” (L. Fazzo, F. Minichilli, M. Santoro, A. Ceccarini, M. Della Seta, F. Bianchi, P. Comba, M. Martuzzi. Hazardous waste and health impact: A systematic review of the scientific literature. Environmental Health (2017) 16: 107), statistically significant excesses of mortality are observed for liver and bladder tumors in both genders, and for breast tumors in women. Significant excesses of incidence are also observed in both genders for liver and bladder tumors, in the male population for breast tumors and in the female population for non-Hodgkin lymphomas. Significant excesses in mortality and incidence are observed in both genders for lung cancer, and these should also be reported in relation to the presence of uncontrolled waste burning sites, the detection of the circulation in the territory of volatile substances emitted from various sources and the high airborne concentrations of polycyclic aromatic hydrocarbons (PAHs) measured in some contexts.
5) Breast cancer mortality is significantly higher in municipalities included in the third and fourth class of the waste exposure indicator compared to municipalities in the first class. This observation can be commented in light of several studies, which have led to the definition of the association of this pathology with waste disposal sites as “limited”; these studies are cited in the systematic review by Fazzo et al, 2017. The analysis of breast cancer incidence data produced by the Tumor Registries also shows an excess of cases in the third and fourth class of the exposure indicator.
6) Hospitalization for asthma is significantly higher in the third and fourth classes of the municipal waste exposure indicator. This association was also defined as limited evidence in the previously cited literature review.
7) The prevalence of preterm births is significantly higher in the municipalities of the third and fourth class of the indicator, compared to the first. This observation can be commented in light of the various studies that have highlighted an excess of preterm births among residents near illegal landfills with volatile emissions, and of the Moniter study relating to incinerators in Emilia-Romagna.
8) With regard to oncological diseases in the pediatric-adolescent age group, which is the subject of particular attention by the population, it should be noted that in the entire area no excesses were recorded for any of the neoplastic sites investigated, compared to the regional average. Individual municipalities present excesses of individual pathologies, which deserve specific attention and in-depth analysis. Even the analyses of mortality and hospital admissions in this age group in the overall area did not record significant excesses, except for tumors of the lymphohematopoietic tissue in the 0-14 age group.
9) As regards the other pathologies, the statistical analysis on the relationship with the waste impact indicator did not give significant signals. Several factors may have contributed to this result, in particular a low statistical power due to the low number of cases examined (due to the rarity of the pathology and/or the brevity of the observation period), or to the absence of an adequate gradient of the values of the municipal indicator of exposure to waste. It should be noted that even the Municipalities of the first class, used as a reference population, still show the presence of uncontrolled disposal sites. The values of the indicator, however, do not show significant dispersion. Therefore, the possible interpretation is that this area, as a whole, represents the component of the Campania region most contaminated by uncontrolled combustion and disposal. Having similar environmental quality data and health indicators relating to the municipalities in the northern part of the Province of Caserta and the southern part of the Province of Naples (excluding the territory of the two capitals), it would be possible to have a more accurate estimate of the health impact of waste improperly disposed of in the Northern Naples District.
The work carried out to collect and analyze all the environmental data available for the territory under examination, despite these limitations, has allowed us to characterize the territory of each of the 38 Municipalities in terms of environmental impact due to the presence of controlled and/or uncontrolled waste disposal sites, highlighting the municipal areas most "impacted"; in addition to this, the collection and analysis of health data from the various available information sources has allowed us to provide a picture of the state of health, highlighting the situations that deserve specific attention. Some Municipalities, in fact, present excesses of specific pathologies in terms of mortality, hospitalization and incidence of tumors. The results of this work, made possible by the collaboration with regional bodies and institutions, although not conclusive, may be the subject of specific interventions.
10) It is desirable to extend the study to all the Municipalities of the Provinces of Naples and Caserta (with the exception of the two capitals, whose demographic characteristics would not be compatible with the study design adopted here), in order to have an adequate proportion of Municipalities without sites of uncontrolled abandonment and combustion, which would represent the internal reference of the analysis against which to make the appropriate comparisons. The Istituto Superiore di Sanità gives its availability to extend the work in this direction, confirming the framework of the collaboration with the Tumor Registries and the Malformation Registry of Campania.
Investigative assessments
The results achieved so far allow us to have a map of the district under the jurisdiction of the Public Prosecutor's Office of North Naples which, without wanting to establish any etiological link, describes, with significant evidence, a correlation between the areas where the most important environmental criticalities have been found and certain tumoral and other types of pathologies.
This important acquisition will allow this Office to base its investigative priorities on scientifically validated bases and to attack the outbreaks of risk exposure considered most dangerous for the health of communities.
The investigation activity will also be directed at verifying the conditions for the possible contestation of the criminal offences introduced by law no. 68 of 2015, and in particular the crime of failure to clean up (art. 452 terdecies CP).
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